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13.7 Resource ClaimResponse - Content

Financial Management Work Group Maturity Level : 2   Trial Use Security Category : Patient Compartments : Patient , Practitioner

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

The ClaimResponse resource provides application level error adjudication results, or an application level adjudication results error, 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 Predetermination or a Pre-Authorization. Preauthorization.This resource is the only appropriate response to a Claim which a processing system recognizes as a Claim resource.

This is the adjudicated response to a Claim, Pre-determination Predetermination or Pre-Authorization. Preauthorization. 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 made. For Preauthorization no payment will actually be made however funds may be reserved to settle a claim submitted later. For Predetermination no payment will actually be made and no assurance is given that the adjudication of a claim submitted later will match the adjudication provided, for example funds may have been exhausted in the interim. Only an actual claim may be expected to result in actual payment.

The ClaimResponse resource is may also be returned with the response for the submission of: Claim, Re-adjudication and Reversals.

The ClaimResponse resource is an "event" resource from a FHIR workflow perspective - see Workflow Event.

Additional information regarding electronic claims content and usage may have been created by interpreting be found at:

  • Financial Resource Status Lifecycle : how .status is used in the corresponding Claim resource financial resources.
  • Secondary Use of Resources : how resources such as a request Claim, ClaimResponse and ExplanationOfBenefit may be used for payment (the oldest sense of a claim), a request reporting and data exchange for preauthorization or a request analytics, not just for predetermination. These interpretations are described at eClaims exchange between providers and payors.
  • Subrogation : how eClaims may handle patient insurance coverages when another insurer rather than the Claim resource. It is possible for provider will settle the consumer claim and potentially recover costs against specified coverages.
  • Coordination of Benefit : how eClaims may handle multiple patient insurance coverages.
  • RealTime Exchange and Obtaining Deferred Responsess : ClaimResponses may be obtained using Polling or FHIR REST (SEARCH).
  • Attachments and Supporting Information : how eClaims may handle the provision of supporting information, whether provided by content or reference, within the ClaimResponse eClaim resource when submitted to know the manner payor or later in a resource which refers to the Claim subject eClaim resource. This also includes how payors may request additional supporting information from providers.

The ClaimResponse resource was processed by checking is used to provide the Claim.use code. results of the adjudication and/or authorization of a set of healthcare-related products and services for a patient against the patient's insurance coverages, or to respond with what the adjudication would be for a supplied set of products or services should they be actually supplied to the patient.

Where The ExplanationOfBenefit resource is for reporting out to patients or transferring data to patient centered applications, such as patient health Record (PHR) application, the producer ExplanationOfBenefit should be used instead of the Claim and ClaimResponse resource interpreted resources as those resources may contain provider and payer specific information which is not appropriate for sharing with the patient.

When using the resources for reporting and transferring claims data, which may have originated in some standard other than FHIR, the Claim as a traditional claim, resource is useful if only the contents request side of the ClaimResponse includes information that the producer exchange is of interest. If, however, both the ClaimResponse intends request and the adjudication information is to pay. The actual payment, however, be reported then the ExplanationOfBenefit should be used instead.

When responding whether the patient's coverage is conveyed separately, perhaps through an eletronic funds transfer protocol outside inforce, whether it is valid at this or a specified date, or returning the domain of FHIR benefit details or possibly by preauthorization requirements associated with a paper check. coverage CoverageEligibilityResponse should be used instead and be the response to a CoverageEligibilityRequest .

However, when The eClaim domain includes a number of related resources
ClaimResponse A payor's adjudication and/or authorization response to the producer suite of services provided in a Claim. Typically the ClaimResponse interpreted references the Claim as request for preauthorization or predetermination, the ClaimResponse but does not imply that such a payment is pending. Actual payment would only follow duplicate the interpretation fo clinical or financial information provided in the claim.
ExplanationOfBenefit This resource combines the information from the Claim and the ClaimResponse, stripping out any provider or payor proprietary information, into a unified information model suitable for use for: patient reporting; transferring information to a Patient Health Record system; and, supporting complete claim and adjudication information exchange with regulatory and analytics organizations and other parts of the provider's organization.
Claim resource as A suite of goods and services and insurances coverages under which adjudication or authorization is requested.
CoverageEligibilityResponse The response to a traditional claim. request to a payor, a CoverageEligibilityRequest , to: ascertain whether a coverage is in-force at the current or at a specified time; list the table of benefits; determine whether coverage is provided for specified categories or specific services; and whether preauthorization is required, and if so what supporting information would be required.

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

This resource implements the Event pattern.

Structure

Name Flags Card. Type Description & Constraints doco
. . ClaimResponse TU DomainResource Remittance resource Response to a claim predetermination or preauthorization
Elements defined in Ancestors: id , meta , implicitRules , language , text , contained , extension , modifierExtension
. . . identifier 0..* Identifier Response number Business Identifier for a claim response
. . . status ?! Σ 0..1 1..1 code active | cancelled | draft | entered-in-error
Financial Resource Status Codes ( Required )
. . . type Σ 0..1 1..1 CodeableConcept Type or discipline More granular claim type
Claim Type Codes ( Extensible )
. . . subType 0..* 0..1 CodeableConcept Finer grained More granular claim type information
Example Claim SubType Codes ( Example )
. . . use Σ 0..1 1..1 code complete | proposed claim | exploratory preauthorization | other predetermination
Use ( Required )
. . . patient Σ 0..1 1..1 Reference ( Patient ) The subject recipient of the Products products and Services services
. . . created Σ 0..1 1..1 dateTime Creation Response creation date
. . . insurer Σ 0..1 1..1 Reference ( Organization ) Insurance issuing organization Party responsible for reimbursement
. . . requestProvider requestor 0..1 Reference ( Practitioner | PractitionerRole | Organization ) Responsible practitioner Party responsible for the claim
. . . request Σ 0..1 Reference ( Claim ) Id of resource triggering adjudication
. . . outcome Σ 0..1 1..1 code queued | complete | error | partial
Claim Processing Codes ( Required )
. . . disposition 0..1 string Disposition Message
. . . preAuthRef 0..1 string Preauthorization reference
.. . preAuthPeriod 0..1 Period Preauthorization reference effective period
... payeeType 0..1 CodeableConcept Party to be paid any benefits payable
Claim Payee Type Codes PayeeType ( Example )
. . . item 0..* BackboneElement Line Adjudication for claim line items
. . . . itemSequence 1..1 positiveInt Service Claim item instance identifier
. . . . noteNumber 0..* positiveInt List of Applicable note numbers which apply
. . . . adjudication 0..* 1..* BackboneElement Adjudication details
. . . . . category 1..1 CodeableConcept Adjudication category such as co-pay, eligible, benefit, etc. Type of adjudication information
Adjudication Value Codes ( Example )
. . . . . reason 0..1 CodeableConcept Explanation of Adjudication adjudication outcome
Adjudication Reason Codes ( Example )
. . . . . amount 0..1 Money Monetary amount
. . . . . value 0..1 decimal Non-monetary value
. . . . detail 0..* BackboneElement Detail line items Adjudication for claim details
. . . . . detailSequence 1..1 positiveInt Service Claim detail instance identifier
. . . . . noteNumber 0..* positiveInt List of Applicable note numbers which apply
. . . . . adjudication 0..* 1..* see adjudication Detail level adjudication details
. . . . . subDetail 0..* BackboneElement Subdetail line items Adjudication for claim sub-details
. . . . . . subDetailSequence 1..1 positiveInt Service Claim sub-detail instance identifier
. . . . . . noteNumber 0..* positiveInt List of Applicable note numbers which apply
. . . . . . adjudication 0..* see adjudication Subdetail level adjudication details
. . . addItem 0..* BackboneElement Insurer added line items
. . . . itemSequence 0..* positiveInt Service instances Item sequence number
. . . . detailSequence 0..* positiveInt Detail sequence number
. . . . subdetailSequence 0..* positiveInt Subdetail sequence number
. . . . provider 0..* Reference ( Practitioner | PractitionerRole | Organization ) Authorized providers
... . service productOrService 0..1 1..1 CodeableConcept Group, Service Billing, service, product, or Product drug code
USCLS Codes ( Example )
. . . . modifier 0..* CodeableConcept Service/Product billing modifiers
Modifier type Codes ( Example )
. . . . fee programCode 0..* CodeableConcept Program the product or service is provided under
Example Program Reason Codes ( Example )
.... serviced[x] 0..1 Date or dates of service or product delivery
..... servicedDate date
..... servicedPeriod Period
.... location[x] 0..1 Place of service or where product was supplied
Example Service Place Codes ( Example )
..... locationCodeableConcept CodeableConcept
..... locationAddress Address
..... locationReference Reference ( Location )
.... quantity 0..1 SimpleQuantity Count of products or services
.... unitPrice 0..1 Money Professional fee or Product Fee, charge or cost per item
. . . . factor 0..1 decimal Price scaling factor
.... net 0..1 Money Total item cost
.... bodySite 0..1 CodeableConcept Anatomical location
Oral Site Codes ( Example )
.... subSite 0..* CodeableConcept Anatomical sub-location
Surface Codes ( Example )
.... noteNumber 0..* positiveInt List of Applicable note numbers which apply
. . . . adjudication 0..* 1..* see adjudication Added items adjudication
. . . . error detail 0..* BackboneElement Processing errors Insurer added line details
. . . . itemSequence . productOrService 1..1 CodeableConcept Billing, service, product, or drug code
USCLS Codes ( Example )
..... modifier 0..* CodeableConcept Service/Product billing modifiers
Modifier type Codes ( Example )
..... quantity 0..1 positiveInt SimpleQuantity Item sequence number Count of products or services
. . . . detailSequence . unitPrice 0..1 positiveInt Money Detail sequence number Fee, charge or cost per item
. . . . . subDetailSequence factor 0..1 decimal Price scaling factor
..... net 0..1 Money Total item cost
..... noteNumber 0..* positiveInt Subdetail sequence number Applicable note numbers
. . . . . adjudication 1..* see adjudication Added items detail adjudication
. . . . . subDetail 0..* BackboneElement Insurer added line items
..... . code productOrService 1..1 CodeableConcept Error Billing, service, product, or drug code detailing processing issues
Adjudication Error USCLS Codes ( Example )
. . . . . . modifier 0..* CodeableConcept Service/Product billing modifiers
Modifier type Codes ( Example )
...... quantity 0..1 SimpleQuantity Count of products or services
...... unitPrice 0..1 Money Fee, charge or cost per item
...... factor 0..1 decimal Price scaling factor
...... net 0..1 Money Total item cost
...... noteNumber 0..* positiveInt Applicable note numbers
...... adjudication 1..* see adjudication Added items detail adjudication
... adjudication 0..* see adjudication Header-level adjudication
. . . total Σ 0..* BackboneElement Adjudication totals
. . . . category Σ 1..1 CodeableConcept Adjudication category such as submitted, co-pay, eligible, benefit, etc. Type of adjudication information
Adjudication Value Codes ( Example )
. . . . amount Σ 1..1 Money Monetary amount Financial total for the category
. . . payment 0..1 BackboneElement Payment details, if paid Details
. . . . type 0..1 1..1 CodeableConcept Partial or Complete complete payment
Example Payment Type Codes ( Example )
. . . . adjustment 0..1 Money Payment adjustment for non-Claim non-claim issues
. . . . adjustmentReason 0..1 CodeableConcept Explanation for the non-claim adjustment
Payment Adjustment Reason Codes ( Example )
. . . . date 0..1 date Expected data date of Payment payment
. . . . amount 0..1 1..1 Money Payable amount after adjustment
. . . . identifier 0..1 Identifier Identifier of Business identifier for the payment instrument
. . . reserved fundsReserve 0..1 Coding CodeableConcept Funds reserved status
Funds Reservation Codes FundsReserve ( Example )
. . . form formCode 0..1 CodeableConcept Printed Form Identifier form identifier
Form Codes Forms ( Example )
. . . form 0..1 Attachment Printed reference or actual form
. . . processNote 0..* BackboneElement Processing notes Note concerning adjudication
. . . . number 0..1 positiveInt Sequence Number for this note Note instance identifier
. . . . type 0..1 code display | print | printoper
NoteType ( Required )
. . . . text 0..1 1..1 string Note explanatory text
. . . . language 0..1 CodeableConcept Language if different from of the resource text
Common Languages ( Extensible Preferred but limited to All Languages AllLanguages )
. . . communicationRequest 0..* Reference ( CommunicationRequest ) Request for additional information
. . . insurance 0..* BackboneElement Insurance or medical plan Patient insurance information
. . . . sequence 1..1 positiveInt Service Insurance instance identifier
. . . . focal 1..1 boolean Is the focal Coverage to be used for adjudication
. . . . coverage 1..1 Reference ( Coverage ) Insurance information
. . . . businessArrangement 0..1 string Business agreement Additional provider contract number
.... claimResponse 0..1 Reference ( ClaimResponse ) Adjudication results
... error 0..* BackboneElement Processing errors
. . . . preAuthRef itemSequence 0..* 0..1 string positiveInt Pre-Authorization/Determination Reference Item sequence number
.... detailSequence 0..1 positiveInt Detail sequence number
.... subDetailSequence 0..1 positiveInt Subdetail sequence number
. . . claimResponse . code 0..1 1..1 Reference CodeableConcept Error code detailing processing issues
AdjudicationError ( ClaimResponse Example ) Adjudication results

doco Documentation for this format

UML Diagram ( Legend )

ClaimResponse ( DomainResource ) The Response business A unique identifier assigned to this claim response identifier : Identifier [0..*] The status of the resource instance (this element modifies the meaning of other elements) status : code [0..1] [1..1] « A code specifying the state of the resource instance. (Strength=Required) Financial Resource Status FinancialResourceStatusCodes ! » The category A finer grained suite of claim, eg, oral, pharmacy, vision, insitutional, professional claim type codes which may convey additional information such as Inpatient vs Outpatient and/or a specialty service type : CodeableConcept [0..1] [1..1] « The type or discipline-style of the claim claim. (Strength=Extensible) Claim Type ClaimTypeCodes + » A finer grained suite of claim subtype type codes which may convey additional information such as Inpatient vs Outpatient and/or a specialty service. In the US the BillType service subType : CodeableConcept [0..*] [0..1] « A more granulat granular claim typecode typecode. (Strength=Example) Example Claim SubType ExampleClaimSubTypeCodes ?? » Complete (Bill A code to indicate whether the nature of the request is: to request adjudication of products and services previously rendered; or Claim), Proposed (Pre-Authorization), Exploratory (Pre-determination) requesting authorization and adjudication for provision in the future; or requesting the non-binding adjudication of the listed products and services which could be provided in the future use : code [0..1] [1..1] « Complete, proposed, exploratory, other Claim, preauthorization, predetermination. (Strength=Required) Use ! » Patient Resource The party to whom the professional services and/or products have been supplied or are being considered and for whom actual for facast reimbursement is sought patient : Reference [0..1] [1..1] « Patient » The date when the enclosed suite of services were performed or completed this resource was created created : dateTime [0..1] [1..1] The Insurer who produced this adjudicated response party responsible for authorization, adjudication and reimbursement insurer : Reference [0..1] [1..1] « Organization » The practitioner who provider which is responsible for the services rendered to the patient claim, predetermination or preauthorization requestProvider requestor : Reference [0..1] « Practitioner | PractitionerRole | Organization » Original request resource referrence reference request : Reference [0..1] « Claim » Transaction: error, complete, partial The outcome of the claim, predetermination, or preauthorization processing outcome : code [0..1] [1..1] « The result of the claim processing processing. (Strength=Required) Claim Processing ClaimProcessingCodes ! » A human readable description of the status of the adjudication disposition : string [0..1] Reference from the Insurer which is used in later communications which refers to this adjudication preAuthRef : string [0..1] The time frame during which this authorization is effective preAuthPeriod : Period [0..1] Type of Party to be reimbursed: Subscriber, subscriber, provider, other payeeType : CodeableConcept [0..1] « A code for the party to be reimbursed. (Strength=Example) Claim Payee Type ?? » Status of funds reservation (For provider, A code, used only on a response to a preauthorization, to indicate whether the benefits payable have been reserved and for Patient, None) whom reserved fundsReserve : Coding CodeableConcept [0..1] « For whom funds are to be reserved: (Patient, Provider, None). (Strength=Example) Funds Reservation ?? » The A code for the form to be used for printing the content form formCode : CodeableConcept [0..1] « The forms codes. (Strength=Example) Form ?? » The actual form, by reference or inclusion, for printing the content or an EOB form : Attachment [0..1] Request for additional supporting or authorizing information, such as: documents, images or resources information communicationRequest : Reference [0..*] « CommunicationRequest » Item A service line number to uniquely reference the claim item entries itemSequence : positiveInt [1..1] A list of note references to the The numbers associated with notes provided below which apply to the adjudication of this item noteNumber : positiveInt [0..*] Adjudication Code indicating: Co-Pay, deductible, eligible, benefit, tax, etc A code to indicate the information type of this adjudication record. Information types may include the value submitted, maximum values or percentages allowed or payable under the plan, amounts that: the patient is responsible for in aggregate or pertaining to this item; amounts paid by other coverages; and, the benefit payable for this item category : CodeableConcept [1..1] « The adjudication codes. (Strength=Example) Adjudication Value AdjudicationValueCodes ?? » Adjudication reason such as limit reached A code supporting the understanding of the adjudication result and explaining variance from expected amount reason : CodeableConcept [0..1] « The adjudication reason codes. (Strength=Example) Adjudication Reason AdjudicationReasonCodes ?? » Monetary amount associated with the code category amount : Money [0..1] A non-monetary value for example a percentage. associated with the category. Mutually exclusive to the amount element above value : decimal [0..1] ItemDetail A service line number to uniquely reference the claim detail entry detailSequence : positiveInt [1..1] A list of note references to the The numbers associated with notes provided below which apply to the adjudication of this item noteNumber : positiveInt [0..*] SubDetail A service line number to uniquely reference the claim sub-detail entry subDetailSequence : positiveInt [1..1] A list of note references to the The numbers associated with notes provided below which apply to the adjudication of this item noteNumber : positiveInt [0..*] AddedItem List of input service Claim items which this service line is intended to replace itemSequence : positiveInt [0..*] The sequence number of the addition details within the line claim item submitted which contains the error. This value is omitted when the error this line is not related intended to an Addition replace detailSequence : positiveInt [0..*] The sequence number of the addition sub-details within the line details within the claim item submitted which contains the error. This value is omitted when the error this line is not related intended to an Addition replace subdetailSequence : positiveInt [0..*] A code The providers who are authorized for the services rendered to indicate the Professional Service patient provider : Reference [0..*] « Practitioner | PractitionerRole | Organization » When the value is a group code then this item collects a set of related claim details, otherwise this contains the product, service, drug or Product supplied other billing code for the item service productOrService : CodeableConcept [0..1] [1..1] « Allowable service and product codes. (Strength=Example) USCLS USCLSCodes ?? » Item typification or modifiers codes to convey additional context for the product or service modifier : CodeableConcept [0..*] « Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or for medical whether an appliance was lost or stolen. (Strength=Example) ModifierTypeCodes ?? » Identifies the treatment program under which this may be recovered programCode : CodeableConcept [0..*] « Program specific reason codes. (Strength=Example) ExampleProgramReasonCodes ?? » The date or dates when the service or product was outside supplied, performed or completed serviced[x] : Type [0..1] « date | Period » Where the clinic product or out service was provided location[x] : Type [0..1] « CodeableConcept | Address | Reference ( Location ); Place of office hours service: pharmacy, school, prison, etc. (Strength=Example) modifier ExampleServicePlaceCodes ?? » The number of repetitions of a service or product quantity : Quantity ( SimpleQuantity ) [0..1] If the item is not a group then this is the fee for the product or service, otherwise this is the total of the fees for the details of the group unitPrice : Money [0..1] A real number that represents a multiplier used in determining the overall value of services delivered and/or goods received. The concept of a Factor allows for a discount or surcharge multiplier to be applied to a monetary amount factor : decimal [0..1] The quantity times the unit price for an additional service or product or charge net : Money [0..1] Physical service site on the patient (limb, tooth, etc.) bodySite : CodeableConcept [0..1] « The code for the teeth, quadrant, sextant and arch. (Strength=Example) OralSiteCodes ?? » A region or surface of the bodySite, e.g. limb region or tooth surface(s) subSite : CodeableConcept [0..*] « The code for the tooth surface and surface combinations. (Strength=Example) SurfaceCodes ?? » The numbers associated with notes below which apply to the adjudication of this item noteNumber : positiveInt [0..*] AddedItemDetail When the value is a group code then this item collects a set of related claim details, otherwise this contains the product, service, drug or other billing code for the item productOrService : CodeableConcept [1..1] « Allowable service and product codes. (Strength=Example) USCLSCodes ?? » Item typification or modifiers codes to convey additional context for the product or service modifier : 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 ModifierTypeCodes ?? » The number of repetitions of a service or product quantity : Quantity ( SimpleQuantity ) [0..1] If the item is not a group then this is the fee charged for the professional service product or product. service, otherwise this is the total of the fees for the details of the group fee unitPrice : Money [0..1] A list real number that represents a multiplier used in determining the overall value of note references services delivered and/or goods received. The concept of a Factor allows for a discount or surcharge multiplier to be applied to a monetary amount factor : decimal [0..1] The quantity times the unit price for an additional service or product or charge net : Money [0..1] The numbers associated with notes provided below which apply to the adjudication of this item noteNumber : positiveInt [0..*] Error AddedItemSubDetail The sequence number of When the line value is a group code then this item submitted which collects a set of related claim details, otherwise this contains the error. This value is omitted when product, service, drug or other billing code for the error is elsewhere item itemSequence productOrService : positiveInt CodeableConcept [0..1] [1..1] « Allowable service and product codes. (Strength=Example) USCLSCodes ?? » Item typification or modifiers codes to convey additional context for the product or service modifier : 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) ModifierTypeCodes ?? » The sequence number of repetitions of a service or product quantity : Quantity ( SimpleQuantity ) [0..1] If the addition within the line item submitted which contains the error. This value is omitted when not a group then this is the error fee for the product or service, otherwise this is not related to an Addition the total of the fees for the details of the group detailSequence unitPrice : positiveInt Money [0..1] The sequence A real number of the addition within the line item submitted which contains that represents a multiplier used in determining the error. This overall value is omitted when the error is not related of services delivered and/or goods received. The concept of a Factor allows for a discount or surcharge multiplier to an Addition be applied to a monetary amount subDetailSequence factor : positiveInt decimal [0..1] An error code,from a specified code system, which details why The quantity times the claim could not be adjudicated unit price for an additional service or product or charge code net : CodeableConcept Money [1..1] « [0..1] The numbers associated with notes below which apply to the adjudication error codes. (Strength=Example) of this item Adjudication Error noteNumber ?? » : positiveInt [0..*] Total Code indicating: Submitted, Co-Pay, deductable, elegible, benefit, tax, etc A code to indicate the information type of this adjudication record. Information types may include: the value submitted, maximum values or percentages allowed or payable under the plan, amounts that the patient is responsible for in aggregate or pertaining to this item, amounts paid by other coverages, and the benefit payable for this item category : CodeableConcept [1..1] « The adjudication codes. (Strength=Example) Adjudication Value AdjudicationValueCodes ?? » Monitory Monetary total amount associated with the code category amount : Money [1..1] Payment Whether this represents partial or complete payment of the claim benefits payable type : CodeableConcept [0..1] [1..1] « The type (partial, complete) of the payment payment. (Strength=Example) Example Payment Type ExamplePaymentTypeCodes ?? » Adjustment Total amount of all adjustments to the this payment of included in this transaction which is are not related to adjudication of this transaction claim's adjudication adjustment : Money [0..1] Reason for the payment adjustment adjustmentReason : CodeableConcept [0..1] « Payment Adjustment reason codes. (Strength=Example) Payment Adjustment Reason PaymentAdjustmentReasonCodes ?? » Estimated date the payment will be issued or the actual issue date of payment data date : date [0..1] Payable Benefits payable less any payment adjustment amount : Money [0..1] [1..1] Payment Issuer's unique identifier for the payment instrument identifier : Identifier [0..1] Note An integer associated with each note which may be referred A number to from each service line item uniquely identify a note entry number : positiveInt [0..1] The business purpose of the note purpose: Print/Display text type : code [0..1] « The presentation types of notes. (Strength=Required) NoteType ! » The note text explanation or description associated with the processing text : string [0..1] [1..1] The ISO-639-1 alpha 2 A code in lower case for to define the language, optionally followed by a hyphen and language used in the ISO-3166-1 alpha 2 code for text of the region in upper case; e.g. "en" for English, or "en-US" for American English versus "en-EN" for England English note language : CodeableConcept [0..1] « A human language. (Strength=Extensible) (Strength=Preferred) Common Languages CommonLanguages + ? » Insurance A service line item number to uniquely identify insurance entries and provide a sequence of coverages to convey coordination of benefit order sequence : positiveInt [1..1] The instance number of the A flag to indicate that this Coverage which is the focus to be used for adjudication. The Coverage against which the adjudication of this claim is when set to be adjudicated true focal : boolean [1..1] Reference to the program or plan identification, underwriter or payor insurance card level information contained in the Coverage resource. The coverage issuing insurer will use these details to locate the patient's actual coverage within the insurer's information system coverage : Reference [1..1] « Coverage » The contract number of a A business agreement which describes number established between the terms provider and conditions the insurer for special business processing purposes businessArrangement : string [0..1] A list The result of references from the Insurer to adjudication of the line items for the Coverage specified in this insurance claimResponse : Reference [0..1] « ClaimResponse » Error The sequence number of the line item submitted which these services pertain contains the error. This value is omitted when the error occurs outside of the item structure preAuthRef itemSequence : string positiveInt [0..*] [0..1] The Coverages adjudication details sequence number of the detail within the line item submitted which contains the error. This value is omitted when the error occurs outside of the item structure claimResponse detailSequence : Reference positiveInt [0..1] The sequence number of the sub-detail within the detail within the line item submitted which contains the error. This value is omitted when the error occurs outside of the item structure subDetailSequence : positiveInt [0..1] An error code, from a specified code system, which details why the claim could not be adjudicated code : CodeableConcept [1..1] « ClaimResponse The adjudication error codes. (Strength=Example) Adjudication Error ?? » The If this item is a group then the values here are a summary of the adjudication results of the detail items. If this item is a simple product or service then this is the result of the adjudication of this item adjudication [0..*] [1..*] The adjudications adjudication results adjudication [0..*] [1..*] The adjudications adjudication results adjudication [0..*] The third tier A sub-detail adjudication of a simple product or service adjudications for submitted services subDetail [0..*] The second tier service adjudications for submitted services A claim detail. Either a simple (a product or service) or a 'group' of sub-details which are simple items detail [0..*] A claim line. Either a simple (a product or service) or a 'group' of details which can also be a simple items or groups of sub-details item [0..*] The first tier adjudication results adjudication [1..*] The adjudication results adjudication [1..*] The adjudication results adjudication [1..*] The third-tier service adjudications for submitted payor added services item subDetail [0..*] The second-tier service adjudications results for payor added services adjudication detail [0..*] The first tier first-tier service adjudications for payor added services product or service lines addItem [0..*] Mutually exclusive with Services Provided (Item) The adjudication results which are presented at the header level rather than at the line-item or add-item levels error adjudication [0..*] Totals Categorized monetary totals for amounts submitted, co-pays, benefits payable etc the adjudication total [0..*] Payment details for the claim if adjudication of the claim has been paid payment [0..1] Note text A note that describes or explains adjudication results in a human readable form processNote [0..*] Financial instrument by which payment information instruments for reimbursement for the health care products and services specified on the claim insurance [0..*] Errors encountered during the processing of the adjudication error [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>
 <
 <</type>
 <</subType>
 <
 <</patient>
 <
 <</insurer>
 <</requestProvider>
 <</request>
 <
 <
 <</payeeType>
 <
  <
  <
  <
   <</category>
   <</reason>
   <</amount>
   <

 <identifier><!-- 0..* Identifier Business Identifier for a claim response --></identifier>
 <status value="[code]"/><!-- 1..1 active | cancelled | draft | entered-in-error -->
 <type><!-- 1..1 CodeableConcept More granular claim type --></type>
 <subType><!-- 0..1 CodeableConcept More granular claim type --></subType>
 <use value="[code]"/><!-- 1..1 claim | preauthorization | predetermination -->
 <patient><!-- 1..1 Reference(Patient) The recipient of the products and services --></patient>
 <created value="[dateTime]"/><!-- 1..1 Response creation date -->
 <insurer><!-- 1..1 Reference(Organization) Party responsible for reimbursement --></insurer>
 <requestor><!-- 0..1 Reference(Organization|Practitioner|PractitionerRole) Party responsible for the claim --></requestor>
 <request><!-- 0..1 Reference(Claim) Id of resource triggering adjudication --></request>
 <outcome value="[code]"/><!-- 1..1 queued | complete | error | partial -->
 <disposition value="[string]"/><!-- 0..1 Disposition Message -->
 <preAuthRef value="[string]"/><!-- 0..1 Preauthorization reference -->
 <preAuthPeriod><!-- 0..1 Period Preauthorization reference effective period --></preAuthPeriod>
 <payeeType><!-- 0..1 CodeableConcept Party to be paid any benefits payable --></payeeType>
 <item>  <!-- 0..* Adjudication for claim line items -->
  <itemSequence value="[positiveInt]"/><!-- 1..1 Claim item instance identifier -->
  <noteNumber value="[positiveInt]"/><!-- 0..* Applicable note numbers -->
  <adjudication>  <!-- 1..* Adjudication details -->
   <category><!-- 1..1 CodeableConcept Type of adjudication information --></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>
  <
   <
   <
   <</adjudication>
   <
    <
    <
    <</adjudication>

  <detail>  <!-- 0..* Adjudication for claim details -->
   <detailSequence value="[positiveInt]"/><!-- 1..1 Claim detail instance identifier -->
   <noteNumber value="[positiveInt]"/><!-- 0..* Applicable note numbers -->
   <adjudication><!-- 1..* Content as for ClaimResponse.item.adjudication Detail level adjudication details --></adjudication>
   <subDetail>  <!-- 0..* Adjudication for claim sub-details -->
    <subDetailSequence value="[positiveInt]"/><!-- 1..1 Claim sub-detail instance identifier -->
    <noteNumber value="[positiveInt]"/><!-- 0..* Applicable note numbers -->
    <adjudication><!-- 0..* Content as for ClaimResponse.item.adjudication Subdetail level adjudication details --></adjudication>

   </subDetail>
  </detail>
 </item>
 <
  <
  <
  <
  <</service>
  <</modifier>
  <</fee>
  <
  <</adjudication>

 <addItem>  <!-- 0..* Insurer added line items -->
  <itemSequence value="[positiveInt]"/><!-- 0..* Item sequence number -->
  <detailSequence value="[positiveInt]"/><!-- 0..* Detail sequence number -->
  <subdetailSequence value="[positiveInt]"/><!-- 0..* Subdetail sequence number -->
  <provider><!-- 0..* Reference(Organization|Practitioner|PractitionerRole) Authorized providers --></provider>
  <productOrService><!-- 1..1 CodeableConcept Billing, service, product, or drug code --></productOrService>
  <modifier><!-- 0..* CodeableConcept Service/Product billing modifiers --></modifier>
  <programCode><!-- 0..* CodeableConcept Program the product or service is provided under --></programCode>
  <serviced[x]><!-- 0..1 date|Period Date or dates of service or product delivery --></serviced[x]>
  <location[x]><!-- 0..1 CodeableConcept|Address|Reference(Location) Place of service or where product was supplied --></location[x]>
  <quantity><!-- 0..1 Quantity(SimpleQuantity) Count of products or services --></quantity>
  <unitPrice><!-- 0..1 Money Fee, charge or cost per item --></unitPrice>
  <factor value="[decimal]"/><!-- 0..1 Price scaling factor -->
  <net><!-- 0..1 Money Total item cost --></net>
  <bodySite><!-- 0..1 CodeableConcept Anatomical location --></bodySite>
  <subSite><!-- 0..* CodeableConcept Anatomical sub-location --></subSite>
  <noteNumber value="[positiveInt]"/><!-- 0..* Applicable note numbers -->
  <adjudication><!-- 1..* Content as for ClaimResponse.item.adjudication Added items adjudication --></adjudication>
  <detail>  <!-- 0..* Insurer added line details -->
   <productOrService><!-- 1..1 CodeableConcept Billing, service, product, or drug code --></productOrService>
   <modifier><!-- 0..* CodeableConcept Service/Product billing modifiers --></modifier>
   <quantity><!-- 0..1 Quantity(SimpleQuantity) Count of products or services --></quantity>
   <unitPrice><!-- 0..1 Money Fee, charge or cost per item --></unitPrice>
   <factor value="[decimal]"/><!-- 0..1 Price scaling factor -->
   <net><!-- 0..1 Money Total item cost --></net>
   <noteNumber value="[positiveInt]"/><!-- 0..* Applicable note numbers -->
   <adjudication><!-- 1..* Content as for ClaimResponse.item.adjudication Added items detail adjudication --></adjudication>
   <subDetail>  <!-- 0..* Insurer added line items -->
    <productOrService><!-- 1..1 CodeableConcept Billing, service, product, or drug code --></productOrService>
    <modifier><!-- 0..* CodeableConcept Service/Product billing modifiers --></modifier>
    <quantity><!-- 0..1 Quantity(SimpleQuantity) Count of products or services --></quantity>
    <unitPrice><!-- 0..1 Money Fee, charge or cost per item --></unitPrice>
    <factor value="[decimal]"/><!-- 0..1 Price scaling factor -->
    <net><!-- 0..1 Money Total item cost --></net>
    <noteNumber value="[positiveInt]"/><!-- 0..* Applicable note numbers -->
    <adjudication><!-- 1..* Content as for ClaimResponse.item.adjudication Added items detail adjudication --></adjudication>
   </subDetail>
  </detail>

 </addItem>
 <
  <
  <
  <
  <</code>
 </error>
 <
  <</category>
  <</amount>

 <adjudication><!-- 0..* Content as for ClaimResponse.item.adjudication Header-level adjudication --></adjudication>
 <total>  <!-- 0..* Adjudication totals -->
  <category><!-- 1..1 CodeableConcept Type of adjudication information --></category>
  <amount><!-- 1..1 Money Financial total for the category --></amount>

 </total>
 <
  <</type>
  <</adjustment>
  <</adjustmentReason>
  <
  <</amount>
  <</identifier>

 <payment>  <!-- 0..1 Payment Details -->
  <type><!-- 1..1 CodeableConcept Partial or complete payment --></type>
  <adjustment><!-- 0..1 Money Payment adjustment for non-claim issues --></adjustment>
  <adjustmentReason><!-- 0..1 CodeableConcept Explanation for the adjustment --></adjustmentReason>
  <date value="[date]"/><!-- 0..1 Expected date of payment -->
  <amount><!-- 1..1 Money Payable amount after adjustment --></amount>
  <identifier><!-- 0..1 Identifier Business identifier for the payment --></identifier>

 </payment>
 <</reserved>
 <</form>
 <
  <
  <
  <
  <</language>

 <fundsReserve><!-- 0..1 CodeableConcept Funds reserved status --></fundsReserve>
 <formCode><!-- 0..1 CodeableConcept Printed form identifier --></formCode>
 <form><!-- 0..1 Attachment Printed reference or actual form --></form>
 <processNote>  <!-- 0..* Note concerning adjudication -->
  <number value="[positiveInt]"/><!-- 0..1 Note instance identifier -->
  <type value="[code]"/><!-- 0..1 display | print | printoper -->
  <text value="[string]"/><!-- 1..1 Note explanatory text -->
  <language><!-- 0..1 CodeableConcept Language of the text --></language>

 </processNote>
 <</communicationRequest>
 <
  <
  <
  <</coverage>
  <
  <
  <</claimResponse>

 <communicationRequest><!-- 0..* Reference(CommunicationRequest) Request for additional information --></communicationRequest>
 <insurance>  <!-- 0..* Patient insurance information -->
  <sequence value="[positiveInt]"/><!-- 1..1 Insurance instance identifier -->
  <focal value="[boolean]"/><!-- 1..1 Coverage to be used for adjudication -->
  <coverage><!-- 1..1 Reference(Coverage) Insurance information --></coverage>
  <businessArrangement value="[string]"/><!-- 0..1 Additional provider contract number -->
  <claimResponse><!-- 0..1 Reference(ClaimResponse) Adjudication results --></claimResponse>

 </insurance>
 <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>

</ClaimResponse>

JSON Template

{doco
  "resourceType" : "ClaimResponse",
  // from Resource: id, meta, implicitRules, and language
  // from DomainResource: text, contained, extension, and modifierExtension
  "
  "
  "
  "
  "
  "
  "
  "
  "
  "
  "
  "
  "
  "
    "
    "
    "
      "
      "
      "
      "

  "identifier" : [{ Identifier }], // Business Identifier for a claim response
  "status" : "<code>", // R!  active | cancelled | draft | entered-in-error
  "type" : { CodeableConcept }, // R!  More granular claim type
  "subType" : { CodeableConcept }, // More granular claim type
  "use" : "<code>", // R!  claim | preauthorization | predetermination
  "patient" : { Reference(Patient) }, // R!  The recipient of the products and services
  "created" : "<dateTime>", // R!  Response creation date
  "insurer" : { Reference(Organization) }, // R!  Party responsible for reimbursement
  "requestor" : { Reference(Organization|Practitioner|PractitionerRole) }, // Party responsible for the claim
  "request" : { Reference(Claim) }, // Id of resource triggering adjudication
  "outcome" : "<code>", // R!  queued | complete | error | partial
  "disposition" : "<string>", // Disposition Message
  "preAuthRef" : "<string>", // Preauthorization reference
  "preAuthPeriod" : { Period }, // Preauthorization reference effective period
  "payeeType" : { CodeableConcept }, // Party to be paid any benefits payable
  "item" : [{ // Adjudication for claim line items
    "itemSequence" : "<positiveInt>", // R!  Claim item instance identifier
    "noteNumber" : ["<positiveInt>"], // Applicable note numbers
    "adjudication" : [{ // R!  Adjudication details
      "category" : { CodeableConcept }, // R!  Type of adjudication information
      "reason" : { CodeableConcept }, // Explanation of adjudication outcome
      "amount" : { Money }, // Monetary amount
      "value" : <decimal> // Non-monetary value

    }],
    "
      "
      "
      "
      "
        "
        "
        "

    "detail" : [{ // Adjudication for claim details
      "detailSequence" : "<positiveInt>", // R!  Claim detail instance identifier
      "noteNumber" : ["<positiveInt>"], // Applicable note numbers
      "adjudication" : [{ Content as for ClaimResponse.item.adjudication }], // R!  Detail level adjudication details
      "subDetail" : [{ // Adjudication for claim sub-details
        "subDetailSequence" : "<positiveInt>", // R!  Claim sub-detail instance identifier
        "noteNumber" : ["<positiveInt>"], // Applicable note numbers
        "adjudication" : [{ Content as for ClaimResponse.item.adjudication }] // Subdetail level adjudication details

      }]
    }]
  }],
  "
    "
    "
    "
    "
    "
    "
    "
    "
  }],
  "
    "
    "
    "
    "

  "addItem" : [{ // Insurer added line items
    "itemSequence" : ["<positiveInt>"], // Item sequence number
    "detailSequence" : ["<positiveInt>"], // Detail sequence number
    "subdetailSequence" : ["<positiveInt>"], // Subdetail sequence number
    "provider" : [{ Reference(Organization|Practitioner|PractitionerRole) }], // Authorized providers
    "productOrService" : { CodeableConcept }, // R!  Billing, service, product, or drug code
    "modifier" : [{ CodeableConcept }], // Service/Product billing modifiers
    "programCode" : [{ CodeableConcept }], // Program the product or service is provided under
    // serviced[x]: Date or dates of service or product delivery. One of these 2:
    "servicedDate" : "<date>",
    "servicedPeriod" : { Period },
    // location[x]: Place of service or where product was supplied. One of these 3:
    "locationCodeableConcept" : { CodeableConcept },
    "locationAddress" : { Address },
    "locationReference" : { Reference(Location) },
    "quantity" : { Quantity(SimpleQuantity) }, // Count of products or services
    "unitPrice" : { Money }, // Fee, charge or cost per item
    "factor" : <decimal>, // Price scaling factor
    "net" : { Money }, // Total item cost
    "bodySite" : { CodeableConcept }, // Anatomical location
    "subSite" : [{ CodeableConcept }], // Anatomical sub-location
    "noteNumber" : ["<positiveInt>"], // Applicable note numbers
    "adjudication" : [{ Content as for ClaimResponse.item.adjudication }], // R!  Added items adjudication
    "detail" : [{ // Insurer added line details
      "productOrService" : { CodeableConcept }, // R!  Billing, service, product, or drug code
      "modifier" : [{ CodeableConcept }], // Service/Product billing modifiers
      "quantity" : { Quantity(SimpleQuantity) }, // Count of products or services
      "unitPrice" : { Money }, // Fee, charge or cost per item
      "factor" : <decimal>, // Price scaling factor
      "net" : { Money }, // Total item cost
      "noteNumber" : ["<positiveInt>"], // Applicable note numbers
      "adjudication" : [{ Content as for ClaimResponse.item.adjudication }], // R!  Added items detail adjudication
      "subDetail" : [{ // Insurer added line items
        "productOrService" : { CodeableConcept }, // R!  Billing, service, product, or drug code
        "modifier" : [{ CodeableConcept }], // Service/Product billing modifiers
        "quantity" : { Quantity(SimpleQuantity) }, // Count of products or services
        "unitPrice" : { Money }, // Fee, charge or cost per item
        "factor" : <decimal>, // Price scaling factor
        "net" : { Money }, // Total item cost
        "noteNumber" : ["<positiveInt>"], // Applicable note numbers
        "adjudication" : [{ Content as for ClaimResponse.item.adjudication }] // R!  Added items detail adjudication
      }]
    }]

  }],
  "
    "
    "

  "adjudication" : [{ Content as for ClaimResponse.item.adjudication }], // Header-level adjudication
  "total" : [{ // Adjudication totals
    "category" : { CodeableConcept }, // R!  Type of adjudication information
    "amount" : { Money } // R!  Financial total for the category

  }],
  "
    "
    "
    "
    "
    "
    "

  "payment" : { // Payment Details
    "type" : { CodeableConcept }, // R!  Partial or complete payment
    "adjustment" : { Money }, // Payment adjustment for non-claim issues
    "adjustmentReason" : { CodeableConcept }, // Explanation for the adjustment
    "date" : "<date>", // Expected date of payment
    "amount" : { Money }, // R!  Payable amount after adjustment
    "identifier" : { Identifier } // Business identifier for the payment

  },
  "
  "
  "
    "
    "
    "
    "

  "fundsReserve" : { CodeableConcept }, // Funds reserved status
  "formCode" : { CodeableConcept }, // Printed form identifier
  "form" : { Attachment }, // Printed reference or actual form
  "processNote" : [{ // Note concerning adjudication
    "number" : "<positiveInt>", // Note instance identifier
    "type" : "<code>", // display | print | printoper
    "text" : "<string>", // R!  Note explanatory text
    "language" : { CodeableConcept } // Language of the text

  }],
  "
  "
    "
    "
    "
    "
    "
    "

  "communicationRequest" : [{ Reference(CommunicationRequest) }], // Request for additional information
  "insurance" : [{ // Patient insurance information
    "sequence" : "<positiveInt>", // R!  Insurance instance identifier
    "focal" : <boolean>, // R!  Coverage to be used for adjudication
    "coverage" : { Reference(Coverage) }, // R!  Insurance information
    "businessArrangement" : "<string>", // Additional provider contract number
    "claimResponse" : { Reference(ClaimResponse) } // Adjudication results
  }],
  "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

  }]
}

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:
  fhir:
  fhir:
  fhir:
  fhir:
  fhir:
  fhir:
  fhir:
  fhir:
  fhir:
  fhir:
  fhir:
  fhir:
  fhir:
    fhir:
    fhir:
    fhir:
      fhir:
      fhir:
      fhir:
      fhir:

  fhir:ClaimResponse.identifier [ Identifier ], ... ; # 0..* Business Identifier for a claim response
  fhir:ClaimResponse.status [ code ]; # 1..1 active | cancelled | draft | entered-in-error
  fhir:ClaimResponse.type [ CodeableConcept ]; # 1..1 More granular claim type
  fhir:ClaimResponse.subType [ CodeableConcept ]; # 0..1 More granular claim type
  fhir:ClaimResponse.use [ code ]; # 1..1 claim | preauthorization | predetermination
  fhir:ClaimResponse.patient [ Reference(Patient) ]; # 1..1 The recipient of the products and services
  fhir:ClaimResponse.created [ dateTime ]; # 1..1 Response creation date
  fhir:ClaimResponse.insurer [ Reference(Organization) ]; # 1..1 Party responsible for reimbursement
  fhir:ClaimResponse.requestor [ Reference(Organization|Practitioner|PractitionerRole) ]; # 0..1 Party responsible for the claim
  fhir:ClaimResponse.request [ Reference(Claim) ]; # 0..1 Id of resource triggering adjudication
  fhir:ClaimResponse.outcome [ code ]; # 1..1 queued | complete | error | partial
  fhir:ClaimResponse.disposition [ string ]; # 0..1 Disposition Message
  fhir:ClaimResponse.preAuthRef [ string ]; # 0..1 Preauthorization reference
  fhir:ClaimResponse.preAuthPeriod [ Period ]; # 0..1 Preauthorization reference effective period
  fhir:ClaimResponse.payeeType [ CodeableConcept ]; # 0..1 Party to be paid any benefits payable
  fhir:ClaimResponse.item [ # 0..* Adjudication for claim line items
    fhir:ClaimResponse.item.itemSequence [ positiveInt ]; # 1..1 Claim item instance identifier
    fhir:ClaimResponse.item.noteNumber [ positiveInt ], ... ; # 0..* Applicable note numbers
    fhir:ClaimResponse.item.adjudication [ # 1..* Adjudication details
      fhir:ClaimResponse.item.adjudication.category [ CodeableConcept ]; # 1..1 Type of adjudication information
      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:
      fhir:
      fhir:
      fhir:
      fhir:
        fhir:
        fhir:
        fhir:

    fhir:ClaimResponse.item.detail [ # 0..* Adjudication for claim details
      fhir:ClaimResponse.item.detail.detailSequence [ positiveInt ]; # 1..1 Claim detail instance identifier
      fhir:ClaimResponse.item.detail.noteNumber [ positiveInt ], ... ; # 0..* Applicable note numbers
      fhir:ClaimResponse.item.detail.adjudication [ See ClaimResponse.item.adjudication ], ... ; # 1..* Detail level adjudication details
      fhir:ClaimResponse.item.detail.subDetail [ # 0..* Adjudication for claim sub-details
        fhir:ClaimResponse.item.detail.subDetail.subDetailSequence [ positiveInt ]; # 1..1 Claim sub-detail instance identifier
        fhir:ClaimResponse.item.detail.subDetail.noteNumber [ positiveInt ], ... ; # 0..* Applicable note numbers
        fhir:ClaimResponse.item.detail.subDetail.adjudication [ See ClaimResponse.item.adjudication ], ... ; # 0..* Subdetail level adjudication details

      ], ...;
    ], ...;
  ], ...;
  fhir:
    fhir:
    fhir:
    fhir:
    fhir:
    fhir:
    fhir:
    fhir:
    fhir:
  ], ...;
  fhir:
    fhir:
    fhir:
    fhir:
    fhir:

  fhir:ClaimResponse.addItem [ # 0..* Insurer added line items
    fhir:ClaimResponse.addItem.itemSequence [ positiveInt ], ... ; # 0..* Item sequence number
    fhir:ClaimResponse.addItem.detailSequence [ positiveInt ], ... ; # 0..* Detail sequence number
    fhir:ClaimResponse.addItem.subdetailSequence [ positiveInt ], ... ; # 0..* Subdetail sequence number
    fhir:ClaimResponse.addItem.provider [ Reference(Organization|Practitioner|PractitionerRole) ], ... ; # 0..* Authorized providers
    fhir:ClaimResponse.addItem.productOrService [ CodeableConcept ]; # 1..1 Billing, service, product, or drug code
    fhir:ClaimResponse.addItem.modifier [ CodeableConcept ], ... ; # 0..* Service/Product billing modifiers
    fhir:ClaimResponse.addItem.programCode [ CodeableConcept ], ... ; # 0..* Program the product or service is provided under
    # ClaimResponse.addItem.serviced[x] : 0..1 Date or dates of service or product delivery. One of these 2
      fhir:ClaimResponse.addItem.servicedDate [ date ]
      fhir:ClaimResponse.addItem.servicedPeriod [ Period ]
    # ClaimResponse.addItem.location[x] : 0..1 Place of service or where product was supplied. One of these 3
      fhir:ClaimResponse.addItem.locationCodeableConcept [ CodeableConcept ]
      fhir:ClaimResponse.addItem.locationAddress [ Address ]
      fhir:ClaimResponse.addItem.locationReference [ Reference(Location) ]
    fhir:ClaimResponse.addItem.quantity [ Quantity(SimpleQuantity) ]; # 0..1 Count of products or services
    fhir:ClaimResponse.addItem.unitPrice [ Money ]; # 0..1 Fee, charge or cost per item
    fhir:ClaimResponse.addItem.factor [ decimal ]; # 0..1 Price scaling factor
    fhir:ClaimResponse.addItem.net [ Money ]; # 0..1 Total item cost
    fhir:ClaimResponse.addItem.bodySite [ CodeableConcept ]; # 0..1 Anatomical location
    fhir:ClaimResponse.addItem.subSite [ CodeableConcept ], ... ; # 0..* Anatomical sub-location
    fhir:ClaimResponse.addItem.noteNumber [ positiveInt ], ... ; # 0..* Applicable note numbers
    fhir:ClaimResponse.addItem.adjudication [ See ClaimResponse.item.adjudication ], ... ; # 1..* Added items adjudication
    fhir:ClaimResponse.addItem.detail [ # 0..* Insurer added line details
      fhir:ClaimResponse.addItem.detail.productOrService [ CodeableConcept ]; # 1..1 Billing, service, product, or drug code
      fhir:ClaimResponse.addItem.detail.modifier [ CodeableConcept ], ... ; # 0..* Service/Product billing modifiers
      fhir:ClaimResponse.addItem.detail.quantity [ Quantity(SimpleQuantity) ]; # 0..1 Count of products or services
      fhir:ClaimResponse.addItem.detail.unitPrice [ Money ]; # 0..1 Fee, charge or cost per item
      fhir:ClaimResponse.addItem.detail.factor [ decimal ]; # 0..1 Price scaling factor
      fhir:ClaimResponse.addItem.detail.net [ Money ]; # 0..1 Total item cost
      fhir:ClaimResponse.addItem.detail.noteNumber [ positiveInt ], ... ; # 0..* Applicable note numbers
      fhir:ClaimResponse.addItem.detail.adjudication [ See ClaimResponse.item.adjudication ], ... ; # 1..* Added items detail adjudication
      fhir:ClaimResponse.addItem.detail.subDetail [ # 0..* Insurer added line items
        fhir:ClaimResponse.addItem.detail.subDetail.productOrService [ CodeableConcept ]; # 1..1 Billing, service, product, or drug code
        fhir:ClaimResponse.addItem.detail.subDetail.modifier [ CodeableConcept ], ... ; # 0..* Service/Product billing modifiers
        fhir:ClaimResponse.addItem.detail.subDetail.quantity [ Quantity(SimpleQuantity) ]; # 0..1 Count of products or services
        fhir:ClaimResponse.addItem.detail.subDetail.unitPrice [ Money ]; # 0..1 Fee, charge or cost per item
        fhir:ClaimResponse.addItem.detail.subDetail.factor [ decimal ]; # 0..1 Price scaling factor
        fhir:ClaimResponse.addItem.detail.subDetail.net [ Money ]; # 0..1 Total item cost
        fhir:ClaimResponse.addItem.detail.subDetail.noteNumber [ positiveInt ], ... ; # 0..* Applicable note numbers
        fhir:ClaimResponse.addItem.detail.subDetail.adjudication [ See ClaimResponse.item.adjudication ], ... ; # 1..* Added items detail adjudication
      ], ...;
    ], ...;

  ], ...;
  fhir:
    fhir:
    fhir:

  fhir:ClaimResponse.adjudication [ See ClaimResponse.item.adjudication ], ... ; # 0..* Header-level adjudication
  fhir:ClaimResponse.total [ # 0..* Adjudication totals
    fhir:ClaimResponse.total.category [ CodeableConcept ]; # 1..1 Type of adjudication information
    fhir:ClaimResponse.total.amount [ Money ]; # 1..1 Financial total for the category

  ], ...;
  fhir:
    fhir:
    fhir:
    fhir:
    fhir:
    fhir:
    fhir:

  fhir:ClaimResponse.payment [ # 0..1 Payment Details
    fhir:ClaimResponse.payment.type [ CodeableConcept ]; # 1..1 Partial or complete payment
    fhir:ClaimResponse.payment.adjustment [ Money ]; # 0..1 Payment adjustment for non-claim issues
    fhir:ClaimResponse.payment.adjustmentReason [ CodeableConcept ]; # 0..1 Explanation for the adjustment
    fhir:ClaimResponse.payment.date [ date ]; # 0..1 Expected date of payment
    fhir:ClaimResponse.payment.amount [ Money ]; # 1..1 Payable amount after adjustment
    fhir:ClaimResponse.payment.identifier [ Identifier ]; # 0..1 Business identifier for the payment

  ];
  fhir:
  fhir:
  fhir:
    fhir:
    fhir:
    fhir:
    fhir:

  fhir:ClaimResponse.fundsReserve [ CodeableConcept ]; # 0..1 Funds reserved status
  fhir:ClaimResponse.formCode [ CodeableConcept ]; # 0..1 Printed form identifier
  fhir:ClaimResponse.form [ Attachment ]; # 0..1 Printed reference or actual form
  fhir:ClaimResponse.processNote [ # 0..* Note concerning adjudication
    fhir:ClaimResponse.processNote.number [ positiveInt ]; # 0..1 Note instance identifier
    fhir:ClaimResponse.processNote.type [ code ]; # 0..1 display | print | printoper
    fhir:ClaimResponse.processNote.text [ string ]; # 1..1 Note explanatory text
    fhir:ClaimResponse.processNote.language [ CodeableConcept ]; # 0..1 Language of the text

  ], ...;
  fhir:
  fhir:
    fhir:
    fhir:
    fhir:
    fhir:
    fhir:
    fhir:

  fhir:ClaimResponse.communicationRequest [ Reference(CommunicationRequest) ], ... ; # 0..* Request for additional information
  fhir:ClaimResponse.insurance [ # 0..* Patient insurance information
    fhir:ClaimResponse.insurance.sequence [ positiveInt ]; # 1..1 Insurance instance identifier
    fhir:ClaimResponse.insurance.focal [ boolean ]; # 1..1 Coverage to be used for adjudication
    fhir:ClaimResponse.insurance.coverage [ Reference(Coverage) ]; # 1..1 Insurance information
    fhir:ClaimResponse.insurance.businessArrangement [ string ]; # 0..1 Additional provider contract number
    fhir:ClaimResponse.insurance.claimResponse [ Reference(ClaimResponse) ]; # 0..1 Adjudication results
  ], ...;
  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

  ], ...;
]

Changes since R3

ClaimResponse.type Added Element ClaimResponse.subType Added Element
ClaimResponse
ClaimResponse.use ClaimResponse.status
  • Added Element Change value set from http://hl7.org/fhir/ValueSet/fm-status|4.0.0 to http://hl7.org/fhir/ValueSet/fm-status|4.1.0
ClaimResponse.requestProvider ClaimResponse.use
  • Type changed Change value set from Reference(Practitioner) http://hl7.org/fhir/ValueSet/claim-use|4.0.0 to Reference(Practitioner|PractitionerRole|Organization) http://hl7.org/fhir/ValueSet/claim-use|4.1.0
ClaimResponse.outcome
  • Type changed Change value set from CodeableConcept http://hl7.org/fhir/ValueSet/remittance-outcome|4.0.0 to code Add Binding http://hl7.org/fhir/ValueSet/remittance-outcome (required) ClaimResponse.item.itemSequence Added Element ClaimResponse.item.detail.detailSequence Added Element ClaimResponse.item.detail.subDetail.subDetailSequence Added Element ClaimResponse.addItem.itemSequence Added Element ClaimResponse.addItem.detailSequence Added Element ClaimResponse.addItem.subdetailSequence Added Element ClaimResponse.error.itemSequence Added Element ClaimResponse.error.detailSequence Added Element ClaimResponse.error.subDetailSequence Added Element ClaimResponse.total Added Element ClaimResponse.total.category Added Element ClaimResponse.total.amount Added Element http://hl7.org/fhir/ValueSet/remittance-outcome|4.1.0
ClaimResponse.processNote.type
  • Type changed Change value set from CodeableConcept http://hl7.org/fhir/ValueSet/note-type|4.0.0 to code ClaimResponse.requestOrganization deleted ClaimResponse.item.sequenceLinkId deleted ClaimResponse.item.detail.sequenceLinkId deleted ClaimResponse.item.detail.subDetail.sequenceLinkId deleted ClaimResponse.addItem.sequenceLinkId deleted ClaimResponse.addItem.revenue deleted ClaimResponse.addItem.category deleted ClaimResponse.addItem.detail deleted ClaimResponse.error.sequenceLinkId deleted ClaimResponse.error.detailSequenceLinkId deleted ClaimResponse.error.subdetailSequenceLinkId deleted ClaimResponse.totalCost deleted ClaimResponse.unallocDeductable deleted ClaimResponse.totalBenefit deleted http://hl7.org/fhir/ValueSet/note-type|4.1.0

See the Full Difference for further information

This analysis is available as XML or JSON .

See R3 <--> R4 Conversion Maps (status = 1 test that all execute ok. 1 fail round-trip testing and 1 r3 resources are invalid (0 errors). )

Structure

Name Flags Card. Type Description & Constraints doco
. . ClaimResponse TU DomainResource Remittance resource Response to a claim predetermination or preauthorization
Elements defined in Ancestors: id , meta , implicitRules , language , text , contained , extension , modifierExtension
. . . identifier 0..* Identifier Response number Business Identifier for a claim response
. . . status ?! Σ 0..1 1..1 code active | cancelled | draft | entered-in-error
Financial Resource Status Codes ( Required )
. . . type Σ 0..1 1..1 CodeableConcept Type or discipline More granular claim type
Claim Type Codes ( Extensible )
. . . subType 0..* 0..1 CodeableConcept Finer grained More granular claim type information
Example Claim SubType Codes ( Example )
. . . use Σ 0..1 1..1 code complete | proposed claim | exploratory preauthorization | other predetermination
Use ( Required )
. . . patient Σ 0..1 1..1 Reference ( Patient ) The subject recipient of the Products products and Services services
. . . created Σ 0..1 1..1 dateTime Creation Response creation date
. . . insurer Σ 0..1 1..1 Reference ( Organization ) Insurance issuing organization Party responsible for reimbursement
. . . requestProvider requestor 0..1 Reference ( Practitioner | PractitionerRole | Organization ) Responsible practitioner Party responsible for the claim
. . . request Σ 0..1 Reference ( Claim ) Id of resource triggering adjudication
. . . outcome Σ 0..1 1..1 code queued | complete | error | partial
Claim Processing Codes ( Required )
. . . disposition 0..1 string Disposition Message
. . . preAuthRef 0..1 string Preauthorization reference
.. . preAuthPeriod 0..1 Period Preauthorization reference effective period
... payeeType 0..1 CodeableConcept Party to be paid any benefits payable
Claim Payee Type Codes PayeeType ( Example )
. . . item 0..* BackboneElement Line Adjudication for claim line items
. . . . itemSequence 1..1 positiveInt Service Claim item instance identifier
. . . . noteNumber 0..* positiveInt List of Applicable note numbers which apply
. . . . adjudication 0..* 1..* BackboneElement Adjudication details
. . . . . category 1..1 CodeableConcept Adjudication category such as co-pay, eligible, benefit, etc. Type of adjudication information
Adjudication Value Codes ( Example )
. . . . . reason 0..1 CodeableConcept Explanation of Adjudication adjudication outcome
Adjudication Reason Codes ( Example )
. . . . . amount 0..1 Money Monetary amount
. . . . . value 0..1 decimal Non-monetary value
. . . . detail 0..* BackboneElement Detail line items Adjudication for claim details
. . . . . detailSequence 1..1 positiveInt Service Claim detail instance identifier
. . . . . noteNumber 0..* positiveInt List of Applicable note numbers which apply
. . . . . adjudication 0..* 1..* see adjudication Detail level adjudication details
. . . . . subDetail 0..* BackboneElement Subdetail line items Adjudication for claim sub-details
. . . . . . subDetailSequence 1..1 positiveInt Service Claim sub-detail instance identifier
. . . . . . noteNumber 0..* positiveInt List of Applicable note numbers which apply
. . . . . . adjudication 0..* see adjudication Subdetail level adjudication details
. . . addItem 0..* BackboneElement Insurer added line items
. . . . itemSequence 0..* positiveInt Service instances Item sequence number
. . . . detailSequence 0..* positiveInt Detail sequence number
. . . . subdetailSequence 0..* positiveInt Subdetail sequence number
. . . . provider 0..* Reference ( Practitioner | PractitionerRole | Organization ) Authorized providers
... . service productOrService 0..1 1..1 CodeableConcept Group, Service Billing, service, product, or Product drug code
USCLS Codes ( Example )
. . . . modifier 0..* CodeableConcept Service/Product billing modifiers
Modifier type Codes ( Example )
. . . . fee programCode 0..* CodeableConcept Program the product or service is provided under
Example Program Reason Codes ( Example )
.... serviced[x] 0..1 Date or dates of service or product delivery
..... servicedDate date
..... servicedPeriod Period
.... location[x] 0..1 Place of service or where product was supplied
Example Service Place Codes ( Example )
..... locationCodeableConcept CodeableConcept
..... locationAddress Address
..... locationReference Reference ( Location )
.... quantity 0..1 SimpleQuantity Count of products or services
.... unitPrice 0..1 Money Professional fee or Product Fee, charge or cost per item
. . . . factor 0..1 decimal Price scaling factor
.... net 0..1 Money Total item cost
.... bodySite 0..1 CodeableConcept Anatomical location
Oral Site Codes ( Example )
.... subSite 0..* CodeableConcept Anatomical sub-location
Surface Codes ( Example )
.... noteNumber 0..* positiveInt List of Applicable note numbers which apply
. . . . adjudication 0..* 1..* see adjudication Added items adjudication
. . . . error detail 0..* BackboneElement Processing errors Insurer added line details
. . . . itemSequence . productOrService 1..1 CodeableConcept Billing, service, product, or drug code
USCLS Codes ( Example )
..... modifier 0..* CodeableConcept Service/Product billing modifiers
Modifier type Codes ( Example )
..... quantity 0..1 positiveInt SimpleQuantity Item sequence number Count of products or services
. . . . detailSequence . unitPrice 0..1 positiveInt Money Detail sequence number Fee, charge or cost per item
. . . . . subDetailSequence factor 0..1 decimal Price scaling factor
..... net 0..1 Money Total item cost
..... noteNumber 0..* positiveInt Subdetail sequence number Applicable note numbers
. . . . . adjudication 1..* see adjudication Added items detail adjudication
. . . . . subDetail 0..* BackboneElement Insurer added line items
..... . code productOrService 1..1 CodeableConcept Error Billing, service, product, or drug code detailing processing issues
Adjudication Error USCLS Codes ( Example )
. . . . . . modifier 0..* CodeableConcept Service/Product billing modifiers
Modifier type Codes ( Example )
...... quantity 0..1 SimpleQuantity Count of products or services
...... unitPrice 0..1 Money Fee, charge or cost per item
...... factor 0..1 decimal Price scaling factor
...... net 0..1 Money Total item cost
...... noteNumber 0..* positiveInt Applicable note numbers
...... adjudication 1..* see adjudication Added items detail adjudication
... adjudication 0..* see adjudication Header-level adjudication
. . . total Σ 0..* BackboneElement Adjudication totals
. . . . category Σ 1..1 CodeableConcept Adjudication category such as submitted, co-pay, eligible, benefit, etc. Type of adjudication information
Adjudication Value Codes ( Example )
. . . . amount Σ 1..1 Money Monetary amount Financial total for the category
. . . payment 0..1 BackboneElement Payment details, if paid Details
. . . . type 0..1 1..1 CodeableConcept Partial or Complete complete payment
Example Payment Type Codes ( Example )
. . . . adjustment 0..1 Money Payment adjustment for non-Claim non-claim issues
. . . . adjustmentReason 0..1 CodeableConcept Explanation for the non-claim adjustment
Payment Adjustment Reason Codes ( Example )
. . . . date 0..1 date Expected data date of Payment payment
. . . . amount 0..1 1..1 Money Payable amount after adjustment
. . . . identifier 0..1 Identifier Identifier of Business identifier for the payment instrument
. . . reserved fundsReserve 0..1 Coding CodeableConcept Funds reserved status
Funds Reservation Codes FundsReserve ( Example )
. . . form formCode 0..1 CodeableConcept Printed Form Identifier form identifier
Form Codes Forms ( Example )
. . . form 0..1 Attachment Printed reference or actual form
. . . processNote 0..* BackboneElement Processing notes Note concerning adjudication
. . . . number 0..1 positiveInt Sequence Number for this note Note instance identifier
. . . . type 0..1 code display | print | printoper
NoteType ( Required )
. . . . text 0..1 1..1 string Note explanatory text
. . . . language 0..1 CodeableConcept Language if different from of the resource text
Common Languages ( Extensible Preferred but limited to All Languages AllLanguages )
. . . communicationRequest 0..* Reference ( CommunicationRequest ) Request for additional information
. . . insurance 0..* BackboneElement Insurance or medical plan Patient insurance information
. . . . sequence 1..1 positiveInt Service Insurance instance identifier
. . . . focal 1..1 boolean Is the focal Coverage to be used for adjudication
. . . . coverage 1..1 Reference ( Coverage ) Insurance information
. . . . businessArrangement 0..1 string Business agreement Additional provider contract number
.... claimResponse 0..1 Reference ( ClaimResponse ) Adjudication results
... error 0..* BackboneElement Processing errors
. . . . preAuthRef itemSequence 0..* 0..1 string positiveInt Item sequence number
.... detailSequence Pre-Authorization/Determination Reference 0..1 positiveInt Detail sequence number
.... subDetailSequence 0..1 positiveInt Subdetail sequence number
. . . claimResponse . code 0..1 1..1 Reference CodeableConcept Error code detailing processing issues
AdjudicationError ( ClaimResponse Example ) Adjudication results

doco Documentation for this format

UML Diagram ( Legend )

ClaimResponse ( DomainResource ) The Response business A unique identifier assigned to this claim response identifier : Identifier [0..*] The status of the resource instance (this element modifies the meaning of other elements) status : code [0..1] [1..1] « A code specifying the state of the resource instance. (Strength=Required) Financial Resource Status FinancialResourceStatusCodes ! » The category A finer grained suite of claim, eg, oral, pharmacy, vision, insitutional, professional claim type codes which may convey additional information such as Inpatient vs Outpatient and/or a specialty service type : CodeableConcept [0..1] [1..1] « The type or discipline-style of the claim claim. (Strength=Extensible) Claim Type ClaimTypeCodes + » A finer grained suite of claim subtype type codes which may convey additional information such as Inpatient vs Outpatient and/or a specialty service. In the US the BillType service subType : CodeableConcept [0..*] [0..1] « A more granulat granular claim typecode typecode. (Strength=Example) Example Claim SubType ExampleClaimSubTypeCodes ?? » Complete (Bill A code to indicate whether the nature of the request is: to request adjudication of products and services previously rendered; or Claim), Proposed (Pre-Authorization), Exploratory (Pre-determination) requesting authorization and adjudication for provision in the future; or requesting the non-binding adjudication of the listed products and services which could be provided in the future use : code [0..1] [1..1] « Complete, proposed, exploratory, other Claim, preauthorization, predetermination. (Strength=Required) Use ! » Patient Resource The party to whom the professional services and/or products have been supplied or are being considered and for whom actual for facast reimbursement is sought patient : Reference [0..1] [1..1] « Patient » The date when the enclosed suite of services were performed or completed this resource was created created : dateTime [0..1] [1..1] The Insurer who produced this adjudicated response party responsible for authorization, adjudication and reimbursement insurer : Reference [0..1] [1..1] « Organization » The practitioner who provider which is responsible for the services rendered to the patient claim, predetermination or preauthorization requestProvider requestor : Reference [0..1] « Practitioner | PractitionerRole | Organization » Original request resource referrence reference request : Reference [0..1] « Claim » Transaction: error, complete, partial The outcome of the claim, predetermination, or preauthorization processing outcome : code [0..1] [1..1] « The result of the claim processing processing. (Strength=Required) Claim Processing ClaimProcessingCodes ! » A human readable description of the status of the adjudication disposition : string [0..1] Reference from the Insurer which is used in later communications which refers to this adjudication preAuthRef : string [0..1] The time frame during which this authorization is effective preAuthPeriod : Period [0..1] Type of Party to be reimbursed: Subscriber, subscriber, provider, other payeeType : CodeableConcept [0..1] « A code for the party to be reimbursed. (Strength=Example) Claim Payee Type ?? » Status of funds reservation (For provider, A code, used only on a response to a preauthorization, to indicate whether the benefits payable have been reserved and for Patient, None) whom reserved fundsReserve : Coding CodeableConcept [0..1] « For whom funds are to be reserved: (Patient, Provider, None). (Strength=Example) Funds Reservation ?? » The A code for the form to be used for printing the content form formCode : CodeableConcept [0..1] « The forms codes. (Strength=Example) Form ?? » The actual form, by reference or inclusion, for printing the content or an EOB form : Attachment [0..1] Request for additional supporting or authorizing information, such as: documents, images or resources information communicationRequest : Reference [0..*] « CommunicationRequest » Item A service line number to uniquely reference the claim item entries itemSequence : positiveInt [1..1] A list of note references to the The numbers associated with notes provided below which apply to the adjudication of this item noteNumber : positiveInt [0..*] Adjudication Code indicating: Co-Pay, deductible, eligible, benefit, tax, etc A code to indicate the information type of this adjudication record. Information types may include the value submitted, maximum values or percentages allowed or payable under the plan, amounts that: the patient is responsible for in aggregate or pertaining to this item; amounts paid by other coverages; and, the benefit payable for this item category : CodeableConcept [1..1] « The adjudication codes. (Strength=Example) Adjudication Value AdjudicationValueCodes ?? » Adjudication reason such as limit reached A code supporting the understanding of the adjudication result and explaining variance from expected amount reason : CodeableConcept [0..1] « The adjudication reason codes. (Strength=Example) Adjudication Reason AdjudicationReasonCodes ?? » Monetary amount associated with the code category amount : Money [0..1] A non-monetary value for example a percentage. associated with the category. Mutually exclusive to the amount element above value : decimal [0..1] ItemDetail A service line number to uniquely reference the claim detail entry detailSequence : positiveInt [1..1] A list of note references to the The numbers associated with notes provided below which apply to the adjudication of this item noteNumber : positiveInt [0..*] SubDetail A service line number to uniquely reference the claim sub-detail entry subDetailSequence : positiveInt [1..1] A list of note references to the The numbers associated with notes provided below which apply to the adjudication of this item noteNumber : positiveInt [0..*] AddedItem List of input service Claim items which this service line is intended to replace itemSequence : positiveInt [0..*] The sequence number of the addition details within the line claim item submitted which contains the error. This value is omitted when the error this line is not related intended to an Addition replace detailSequence : positiveInt [0..*] The sequence number of the addition sub-details within the line details within the claim item submitted which contains the error. This value is omitted when the error this line is not related intended to an Addition replace subdetailSequence : positiveInt [0..*] A code The providers who are authorized for the services rendered to indicate the Professional Service patient provider : Reference [0..*] « Practitioner | PractitionerRole | Organization » When the value is a group code then this item collects a set of related claim details, otherwise this contains the product, service, drug or Product supplied other billing code for the item service productOrService : CodeableConcept [0..1] [1..1] « Allowable service and product codes. (Strength=Example) USCLS USCLSCodes ?? » Item typification or modifiers codes to convey additional context for the product or service modifier : CodeableConcept [0..*] « Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or for medical whether an appliance was lost or stolen. (Strength=Example) ModifierTypeCodes ?? » Identifies the treatment program under which this may be recovered programCode : CodeableConcept [0..*] « Program specific reason codes. (Strength=Example) ExampleProgramReasonCodes ?? » The date or dates when the service or product was outside supplied, performed or completed serviced[x] : Type [0..1] « date | Period » Where the clinic product or out service was provided location[x] : Type [0..1] « CodeableConcept | Address | Reference ( Location ); Place of office hours service: pharmacy, school, prison, etc. (Strength=Example) modifier ExampleServicePlaceCodes ?? » The number of repetitions of a service or product quantity : Quantity ( SimpleQuantity ) [0..1] If the item is not a group then this is the fee for the product or service, otherwise this is the total of the fees for the details of the group unitPrice : Money [0..1] A real number that represents a multiplier used in determining the overall value of services delivered and/or goods received. The concept of a Factor allows for a discount or surcharge multiplier to be applied to a monetary amount factor : decimal [0..1] The quantity times the unit price for an additional service or product or charge net : Money [0..1] Physical service site on the patient (limb, tooth, etc.) bodySite : CodeableConcept [0..1] « The code for the teeth, quadrant, sextant and arch. (Strength=Example) OralSiteCodes ?? » A region or surface of the bodySite, e.g. limb region or tooth surface(s) subSite : CodeableConcept [0..*] « The code for the tooth surface and surface combinations. (Strength=Example) SurfaceCodes ?? » The numbers associated with notes below which apply to the adjudication of this item noteNumber : positiveInt [0..*] AddedItemDetail When the value is a group code then this item collects a set of related claim details, otherwise this contains the product, service, drug or other billing code for the item productOrService : CodeableConcept [1..1] « Allowable service and product codes. (Strength=Example) USCLSCodes ?? » Item typification or modifiers codes to convey additional context for the product or service modifier : 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 ModifierTypeCodes ?? » The number of repetitions of a service or product quantity : Quantity ( SimpleQuantity ) [0..1] If the item is not a group then this is the fee charged for the professional service product or product. service, otherwise this is the total of the fees for the details of the group fee unitPrice : Money [0..1] A list real number that represents a multiplier used in determining the overall value of note references services delivered and/or goods received. The concept of a Factor allows for a discount or surcharge multiplier to be applied to a monetary amount factor : decimal [0..1] The quantity times the unit price for an additional service or product or charge net : Money [0..1] The numbers associated with notes provided below which apply to the adjudication of this item noteNumber : positiveInt [0..*] Error AddedItemSubDetail The sequence number of When the line value is a group code then this item submitted which collects a set of related claim details, otherwise this contains the error. This value is omitted when product, service, drug or other billing code for the error is elsewhere item itemSequence productOrService : positiveInt CodeableConcept [0..1] [1..1] « Allowable service and product codes. (Strength=Example) USCLSCodes ?? » Item typification or modifiers codes to convey additional context for the product or service modifier : 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) ModifierTypeCodes ?? » The sequence number of repetitions of a service or product quantity : Quantity ( SimpleQuantity ) [0..1] If the addition within the line item submitted which contains the error. This value is omitted when not a group then this is the error fee for the product or service, otherwise this is not related to an Addition the total of the fees for the details of the group detailSequence unitPrice : positiveInt Money [0..1] The sequence A real number of the addition within the line item submitted which contains that represents a multiplier used in determining the error. This overall value is omitted when the error is not related of services delivered and/or goods received. The concept of a Factor allows for a discount or surcharge multiplier to an Addition be applied to a monetary amount subDetailSequence factor : positiveInt decimal [0..1] An error code,from a specified code system, which details why The quantity times the claim could not be adjudicated unit price for an additional service or product or charge code net : CodeableConcept Money [1..1] « [0..1] The numbers associated with notes below which apply to the adjudication error codes. (Strength=Example) of this item Adjudication Error noteNumber ?? » : positiveInt [0..*] Total Code indicating: Submitted, Co-Pay, deductable, elegible, benefit, tax, etc A code to indicate the information type of this adjudication record. Information types may include: the value submitted, maximum values or percentages allowed or payable under the plan, amounts that the patient is responsible for in aggregate or pertaining to this item, amounts paid by other coverages, and the benefit payable for this item category : CodeableConcept [1..1] « The adjudication codes. (Strength=Example) Adjudication Value AdjudicationValueCodes ?? » Monitory Monetary total amount associated with the code category amount : Money [1..1] Payment Whether this represents partial or complete payment of the claim benefits payable type : CodeableConcept [0..1] [1..1] « The type (partial, complete) of the payment payment. (Strength=Example) Example Payment Type ExamplePaymentTypeCodes ?? » Adjustment Total amount of all adjustments to the this payment of included in this transaction which is are not related to adjudication of this transaction claim's adjudication adjustment : Money [0..1] Reason for the payment adjustment adjustmentReason : CodeableConcept [0..1] « Payment Adjustment reason codes. (Strength=Example) Payment Adjustment Reason PaymentAdjustmentReasonCodes ?? » Estimated date the payment will be issued or the actual issue date of payment data date : date [0..1] Payable Benefits payable less any payment adjustment amount : Money [0..1] [1..1] Payment Issuer's unique identifier for the payment instrument identifier : Identifier [0..1] Note An integer associated with each note which may be referred A number to from each service line item uniquely identify a note entry number : positiveInt [0..1] The business purpose of the note purpose: Print/Display text type : code [0..1] « The presentation types of notes. (Strength=Required) NoteType ! » The note text explanation or description associated with the processing text : string [0..1] [1..1] The ISO-639-1 alpha 2 A code in lower case for to define the language, optionally followed by a hyphen and language used in the ISO-3166-1 alpha 2 code for text of the region in upper case; e.g. "en" for English, or "en-US" for American English versus "en-EN" for England English note language : CodeableConcept [0..1] « A human language. (Strength=Extensible) (Strength=Preferred) Common Languages CommonLanguages + ? » Insurance A service line item number to uniquely identify insurance entries and provide a sequence of coverages to convey coordination of benefit order sequence : positiveInt [1..1] The instance number of the A flag to indicate that this Coverage which is the focus to be used for adjudication. The Coverage against which the adjudication of this claim is when set to be adjudicated true focal : boolean [1..1] Reference to the program or plan identification, underwriter or payor insurance card level information contained in the Coverage resource. The coverage issuing insurer will use these details to locate the patient's actual coverage within the insurer's information system coverage : Reference [1..1] « Coverage » The contract number of a A business agreement which describes number established between the terms provider and conditions the insurer for special business processing purposes businessArrangement : string [0..1] A list The result of references from the Insurer to adjudication of the line items for the Coverage specified in this insurance claimResponse : Reference [0..1] « ClaimResponse » Error The sequence number of the line item submitted which these services pertain contains the error. This value is omitted when the error occurs outside of the item structure preAuthRef itemSequence : string positiveInt [0..*] [0..1] The Coverages adjudication details sequence number of the detail within the line item submitted which contains the error. This value is omitted when the error occurs outside of the item structure claimResponse detailSequence : Reference positiveInt [0..1] The sequence number of the sub-detail within the detail within the line item submitted which contains the error. This value is omitted when the error occurs outside of the item structure subDetailSequence : positiveInt [0..1] An error code, from a specified code system, which details why the claim could not be adjudicated code : CodeableConcept [1..1] « ClaimResponse The adjudication error codes. (Strength=Example) Adjudication Error ?? » The If this item is a group then the values here are a summary of the adjudication results of the detail items. If this item is a simple product or service then this is the result of the adjudication of this item adjudication [0..*] [1..*] The adjudications adjudication results adjudication [0..*] [1..*] The adjudications adjudication results adjudication [0..*] The third tier A sub-detail adjudication of a simple product or service adjudications for submitted services subDetail [0..*] The second tier service adjudications for submitted services A claim detail. Either a simple (a product or service) or a 'group' of sub-details which are simple items detail [0..*] A claim line. Either a simple (a product or service) or a 'group' of details which can also be a simple items or groups of sub-details item [0..*] The first tier adjudication results adjudication [1..*] The adjudication results adjudication [1..*] The adjudication results adjudication [1..*] The third-tier service adjudications for submitted payor added services item subDetail [0..*] The second-tier service adjudications results for payor added services adjudication detail [0..*] The first tier first-tier service adjudications for payor added services product or service lines addItem [0..*] Mutually exclusive with Services Provided (Item) The adjudication results which are presented at the header level rather than at the line-item or add-item levels error adjudication [0..*] Totals Categorized monetary totals for amounts submitted, co-pays, benefits payable etc the adjudication total [0..*] Payment details for the claim if adjudication of the claim has been paid payment [0..1] Note text A note that describes or explains adjudication results in a human readable form processNote [0..*] Financial instrument by which payment information instruments for reimbursement for the health care products and services specified on the claim insurance [0..*] Errors encountered during the processing of the adjudication error [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>
 <
 <</type>
 <</subType>
 <
 <</patient>
 <
 <</insurer>
 <</requestProvider>
 <</request>
 <
 <
 <</payeeType>
 <
  <
  <
  <
   <</category>
   <</reason>
   <</amount>
   <

 <identifier><!-- 0..* Identifier Business Identifier for a claim response --></identifier>
 <status value="[code]"/><!-- 1..1 active | cancelled | draft | entered-in-error -->
 <type><!-- 1..1 CodeableConcept More granular claim type --></type>
 <subType><!-- 0..1 CodeableConcept More granular claim type --></subType>
 <use value="[code]"/><!-- 1..1 claim | preauthorization | predetermination -->
 <patient><!-- 1..1 Reference(Patient) The recipient of the products and services --></patient>
 <created value="[dateTime]"/><!-- 1..1 Response creation date -->
 <insurer><!-- 1..1 Reference(Organization) Party responsible for reimbursement --></insurer>
 <requestor><!-- 0..1 Reference(Organization|Practitioner|PractitionerRole) Party responsible for the claim --></requestor>
 <request><!-- 0..1 Reference(Claim) Id of resource triggering adjudication --></request>
 <outcome value="[code]"/><!-- 1..1 queued | complete | error | partial -->
 <disposition value="[string]"/><!-- 0..1 Disposition Message -->
 <preAuthRef value="[string]"/><!-- 0..1 Preauthorization reference -->
 <preAuthPeriod><!-- 0..1 Period Preauthorization reference effective period --></preAuthPeriod>
 <payeeType><!-- 0..1 CodeableConcept Party to be paid any benefits payable --></payeeType>
 <item>  <!-- 0..* Adjudication for claim line items -->
  <itemSequence value="[positiveInt]"/><!-- 1..1 Claim item instance identifier -->
  <noteNumber value="[positiveInt]"/><!-- 0..* Applicable note numbers -->
  <adjudication>  <!-- 1..* Adjudication details -->
   <category><!-- 1..1 CodeableConcept Type of adjudication information --></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>
  <
   <
   <
   <</adjudication>
   <
    <
    <
    <</adjudication>

  <detail>  <!-- 0..* Adjudication for claim details -->
   <detailSequence value="[positiveInt]"/><!-- 1..1 Claim detail instance identifier -->
   <noteNumber value="[positiveInt]"/><!-- 0..* Applicable note numbers -->
   <adjudication><!-- 1..* Content as for ClaimResponse.item.adjudication Detail level adjudication details --></adjudication>
   <subDetail>  <!-- 0..* Adjudication for claim sub-details -->
    <subDetailSequence value="[positiveInt]"/><!-- 1..1 Claim sub-detail instance identifier -->
    <noteNumber value="[positiveInt]"/><!-- 0..* Applicable note numbers -->
    <adjudication><!-- 0..* Content as for ClaimResponse.item.adjudication Subdetail level adjudication details --></adjudication>

   </subDetail>
  </detail>
 </item>
 <
  <
  <
  <
  <</service>
  <</modifier>
  <</fee>
  <
  <</adjudication>

 <addItem>  <!-- 0..* Insurer added line items -->
  <itemSequence value="[positiveInt]"/><!-- 0..* Item sequence number -->
  <detailSequence value="[positiveInt]"/><!-- 0..* Detail sequence number -->
  <subdetailSequence value="[positiveInt]"/><!-- 0..* Subdetail sequence number -->
  <provider><!-- 0..* Reference(Organization|Practitioner|PractitionerRole) Authorized providers --></provider>
  <productOrService><!-- 1..1 CodeableConcept Billing, service, product, or drug code --></productOrService>
  <modifier><!-- 0..* CodeableConcept Service/Product billing modifiers --></modifier>
  <programCode><!-- 0..* CodeableConcept Program the product or service is provided under --></programCode>
  <serviced[x]><!-- 0..1 date|Period Date or dates of service or product delivery --></serviced[x]>
  <location[x]><!-- 0..1 CodeableConcept|Address|Reference(Location) Place of service or where product was supplied --></location[x]>
  <quantity><!-- 0..1 Quantity(SimpleQuantity) Count of products or services --></quantity>
  <unitPrice><!-- 0..1 Money Fee, charge or cost per item --></unitPrice>
  <factor value="[decimal]"/><!-- 0..1 Price scaling factor -->
  <net><!-- 0..1 Money Total item cost --></net>
  <bodySite><!-- 0..1 CodeableConcept Anatomical location --></bodySite>
  <subSite><!-- 0..* CodeableConcept Anatomical sub-location --></subSite>
  <noteNumber value="[positiveInt]"/><!-- 0..* Applicable note numbers -->
  <adjudication><!-- 1..* Content as for ClaimResponse.item.adjudication Added items adjudication --></adjudication>
  <detail>  <!-- 0..* Insurer added line details -->
   <productOrService><!-- 1..1 CodeableConcept Billing, service, product, or drug code --></productOrService>
   <modifier><!-- 0..* CodeableConcept Service/Product billing modifiers --></modifier>
   <quantity><!-- 0..1 Quantity(SimpleQuantity) Count of products or services --></quantity>
   <unitPrice><!-- 0..1 Money Fee, charge or cost per item --></unitPrice>
   <factor value="[decimal]"/><!-- 0..1 Price scaling factor -->
   <net><!-- 0..1 Money Total item cost --></net>
   <noteNumber value="[positiveInt]"/><!-- 0..* Applicable note numbers -->
   <adjudication><!-- 1..* Content as for ClaimResponse.item.adjudication Added items detail adjudication --></adjudication>
   <subDetail>  <!-- 0..* Insurer added line items -->
    <productOrService><!-- 1..1 CodeableConcept Billing, service, product, or drug code --></productOrService>
    <modifier><!-- 0..* CodeableConcept Service/Product billing modifiers --></modifier>
    <quantity><!-- 0..1 Quantity(SimpleQuantity) Count of products or services --></quantity>
    <unitPrice><!-- 0..1 Money Fee, charge or cost per item --></unitPrice>
    <factor value="[decimal]"/><!-- 0..1 Price scaling factor -->
    <net><!-- 0..1 Money Total item cost --></net>
    <noteNumber value="[positiveInt]"/><!-- 0..* Applicable note numbers -->
    <adjudication><!-- 1..* Content as for ClaimResponse.item.adjudication Added items detail adjudication --></adjudication>
   </subDetail>
  </detail>

 </addItem>
 <
  <
  <
  <
  <</code>
 </error>
 <
  <</category>
  <</amount>

 <adjudication><!-- 0..* Content as for ClaimResponse.item.adjudication Header-level adjudication --></adjudication>
 <total>  <!-- 0..* Adjudication totals -->
  <category><!-- 1..1 CodeableConcept Type of adjudication information --></category>
  <amount><!-- 1..1 Money Financial total for the category --></amount>

 </total>
 <
  <</type>
  <</adjustment>
  <</adjustmentReason>
  <
  <</amount>
  <</identifier>

 <payment>  <!-- 0..1 Payment Details -->
  <type><!-- 1..1 CodeableConcept Partial or complete payment --></type>
  <adjustment><!-- 0..1 Money Payment adjustment for non-claim issues --></adjustment>
  <adjustmentReason><!-- 0..1 CodeableConcept Explanation for the adjustment --></adjustmentReason>
  <date value="[date]"/><!-- 0..1 Expected date of payment -->
  <amount><!-- 1..1 Money Payable amount after adjustment --></amount>
  <identifier><!-- 0..1 Identifier Business identifier for the payment --></identifier>

 </payment>
 <</reserved>
 <</form>
 <
  <
  <
  <
  <</language>

 <fundsReserve><!-- 0..1 CodeableConcept Funds reserved status --></fundsReserve>
 <formCode><!-- 0..1 CodeableConcept Printed form identifier --></formCode>
 <form><!-- 0..1 Attachment Printed reference or actual form --></form>
 <processNote>  <!-- 0..* Note concerning adjudication -->
  <number value="[positiveInt]"/><!-- 0..1 Note instance identifier -->
  <type value="[code]"/><!-- 0..1 display | print | printoper -->
  <text value="[string]"/><!-- 1..1 Note explanatory text -->
  <language><!-- 0..1 CodeableConcept Language of the text --></language>

 </processNote>
 <</communicationRequest>
 <
  <
  <
  <</coverage>
  <
  <
  <</claimResponse>

 <communicationRequest><!-- 0..* Reference(CommunicationRequest) Request for additional information --></communicationRequest>
 <insurance>  <!-- 0..* Patient insurance information -->
  <sequence value="[positiveInt]"/><!-- 1..1 Insurance instance identifier -->
  <focal value="[boolean]"/><!-- 1..1 Coverage to be used for adjudication -->
  <coverage><!-- 1..1 Reference(Coverage) Insurance information --></coverage>
  <businessArrangement value="[string]"/><!-- 0..1 Additional provider contract number -->
  <claimResponse><!-- 0..1 Reference(ClaimResponse) Adjudication results --></claimResponse>

 </insurance>
 <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>

</ClaimResponse>

JSON Template

{doco
  "resourceType" : "ClaimResponse",
  // from Resource: id, meta, implicitRules, and language
  // from DomainResource: text, contained, extension, and modifierExtension
  "
  "
  "
  "
  "
  "
  "
  "
  "
  "
  "
  "
  "
  "
    "
    "
    "
      "
      "
      "
      "

  "identifier" : [{ Identifier }], // Business Identifier for a claim response
  "status" : "<code>", // R!  active | cancelled | draft | entered-in-error
  "type" : { CodeableConcept }, // R!  More granular claim type
  "subType" : { CodeableConcept }, // More granular claim type
  "use" : "<code>", // R!  claim | preauthorization | predetermination
  "patient" : { Reference(Patient) }, // R!  The recipient of the products and services
  "created" : "<dateTime>", // R!  Response creation date
  "insurer" : { Reference(Organization) }, // R!  Party responsible for reimbursement
  "requestor" : { Reference(Organization|Practitioner|PractitionerRole) }, // Party responsible for the claim
  "request" : { Reference(Claim) }, // Id of resource triggering adjudication
  "outcome" : "<code>", // R!  queued | complete | error | partial
  "disposition" : "<string>", // Disposition Message
  "preAuthRef" : "<string>", // Preauthorization reference
  "preAuthPeriod" : { Period }, // Preauthorization reference effective period
  "payeeType" : { CodeableConcept }, // Party to be paid any benefits payable
  "item" : [{ // Adjudication for claim line items
    "itemSequence" : "<positiveInt>", // R!  Claim item instance identifier
    "noteNumber" : ["<positiveInt>"], // Applicable note numbers
    "adjudication" : [{ // R!  Adjudication details
      "category" : { CodeableConcept }, // R!  Type of adjudication information
      "reason" : { CodeableConcept }, // Explanation of adjudication outcome
      "amount" : { Money }, // Monetary amount
      "value" : <decimal> // Non-monetary value

    }],
    "
      "
      "
      "
      "
        "
        "
        "

    "detail" : [{ // Adjudication for claim details
      "detailSequence" : "<positiveInt>", // R!  Claim detail instance identifier
      "noteNumber" : ["<positiveInt>"], // Applicable note numbers
      "adjudication" : [{ Content as for ClaimResponse.item.adjudication }], // R!  Detail level adjudication details
      "subDetail" : [{ // Adjudication for claim sub-details
        "subDetailSequence" : "<positiveInt>", // R!  Claim sub-detail instance identifier
        "noteNumber" : ["<positiveInt>"], // Applicable note numbers
        "adjudication" : [{ Content as for ClaimResponse.item.adjudication }] // Subdetail level adjudication details

      }]
    }]
  }],
  "
    "
    "
    "
    "
    "
    "
    "
    "
  }],
  "
    "
    "
    "
    "

  "addItem" : [{ // Insurer added line items
    "itemSequence" : ["<positiveInt>"], // Item sequence number
    "detailSequence" : ["<positiveInt>"], // Detail sequence number
    "subdetailSequence" : ["<positiveInt>"], // Subdetail sequence number
    "provider" : [{ Reference(Organization|Practitioner|PractitionerRole) }], // Authorized providers
    "productOrService" : { CodeableConcept }, // R!  Billing, service, product, or drug code
    "modifier" : [{ CodeableConcept }], // Service/Product billing modifiers
    "programCode" : [{ CodeableConcept }], // Program the product or service is provided under
    // serviced[x]: Date or dates of service or product delivery. One of these 2:
    "servicedDate" : "<date>",
    "servicedPeriod" : { Period },
    // location[x]: Place of service or where product was supplied. One of these 3:
    "locationCodeableConcept" : { CodeableConcept },
    "locationAddress" : { Address },
    "locationReference" : { Reference(Location) },
    "quantity" : { Quantity(SimpleQuantity) }, // Count of products or services
    "unitPrice" : { Money }, // Fee, charge or cost per item
    "factor" : <decimal>, // Price scaling factor
    "net" : { Money }, // Total item cost
    "bodySite" : { CodeableConcept }, // Anatomical location
    "subSite" : [{ CodeableConcept }], // Anatomical sub-location
    "noteNumber" : ["<positiveInt>"], // Applicable note numbers
    "adjudication" : [{ Content as for ClaimResponse.item.adjudication }], // R!  Added items adjudication
    "detail" : [{ // Insurer added line details
      "productOrService" : { CodeableConcept }, // R!  Billing, service, product, or drug code
      "modifier" : [{ CodeableConcept }], // Service/Product billing modifiers
      "quantity" : { Quantity(SimpleQuantity) }, // Count of products or services
      "unitPrice" : { Money }, // Fee, charge or cost per item
      "factor" : <decimal>, // Price scaling factor
      "net" : { Money }, // Total item cost
      "noteNumber" : ["<positiveInt>"], // Applicable note numbers
      "adjudication" : [{ Content as for ClaimResponse.item.adjudication }], // R!  Added items detail adjudication
      "subDetail" : [{ // Insurer added line items
        "productOrService" : { CodeableConcept }, // R!  Billing, service, product, or drug code
        "modifier" : [{ CodeableConcept }], // Service/Product billing modifiers
        "quantity" : { Quantity(SimpleQuantity) }, // Count of products or services
        "unitPrice" : { Money }, // Fee, charge or cost per item
        "factor" : <decimal>, // Price scaling factor
        "net" : { Money }, // Total item cost
        "noteNumber" : ["<positiveInt>"], // Applicable note numbers
        "adjudication" : [{ Content as for ClaimResponse.item.adjudication }] // R!  Added items detail adjudication
      }]
    }]

  }],
  "
    "
    "

  "adjudication" : [{ Content as for ClaimResponse.item.adjudication }], // Header-level adjudication
  "total" : [{ // Adjudication totals
    "category" : { CodeableConcept }, // R!  Type of adjudication information
    "amount" : { Money } // R!  Financial total for the category

  }],
  "
    "
    "
    "
    "
    "
    "

  "payment" : { // Payment Details
    "type" : { CodeableConcept }, // R!  Partial or complete payment
    "adjustment" : { Money }, // Payment adjustment for non-claim issues
    "adjustmentReason" : { CodeableConcept }, // Explanation for the adjustment
    "date" : "<date>", // Expected date of payment
    "amount" : { Money }, // R!  Payable amount after adjustment
    "identifier" : { Identifier } // Business identifier for the payment

  },
  "
  "
  "
    "
    "
    "
    "

  "fundsReserve" : { CodeableConcept }, // Funds reserved status
  "formCode" : { CodeableConcept }, // Printed form identifier
  "form" : { Attachment }, // Printed reference or actual form
  "processNote" : [{ // Note concerning adjudication
    "number" : "<positiveInt>", // Note instance identifier
    "type" : "<code>", // display | print | printoper
    "text" : "<string>", // R!  Note explanatory text
    "language" : { CodeableConcept } // Language of the text

  }],
  "
  "
    "
    "
    "
    "
    "
    "

  "communicationRequest" : [{ Reference(CommunicationRequest) }], // Request for additional information
  "insurance" : [{ // Patient insurance information
    "sequence" : "<positiveInt>", // R!  Insurance instance identifier
    "focal" : <boolean>, // R!  Coverage to be used for adjudication
    "coverage" : { Reference(Coverage) }, // R!  Insurance information
    "businessArrangement" : "<string>", // Additional provider contract number
    "claimResponse" : { Reference(ClaimResponse) } // Adjudication results
  }],
  "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

  }]
}

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:
  fhir:
  fhir:
  fhir:
  fhir:
  fhir:
  fhir:
  fhir:
  fhir:
  fhir:
  fhir:
  fhir:
  fhir:
  fhir:
    fhir:
    fhir:
    fhir:
      fhir:
      fhir:
      fhir:
      fhir:

  fhir:ClaimResponse.identifier [ Identifier ], ... ; # 0..* Business Identifier for a claim response
  fhir:ClaimResponse.status [ code ]; # 1..1 active | cancelled | draft | entered-in-error
  fhir:ClaimResponse.type [ CodeableConcept ]; # 1..1 More granular claim type
  fhir:ClaimResponse.subType [ CodeableConcept ]; # 0..1 More granular claim type
  fhir:ClaimResponse.use [ code ]; # 1..1 claim | preauthorization | predetermination
  fhir:ClaimResponse.patient [ Reference(Patient) ]; # 1..1 The recipient of the products and services
  fhir:ClaimResponse.created [ dateTime ]; # 1..1 Response creation date
  fhir:ClaimResponse.insurer [ Reference(Organization) ]; # 1..1 Party responsible for reimbursement
  fhir:ClaimResponse.requestor [ Reference(Organization|Practitioner|PractitionerRole) ]; # 0..1 Party responsible for the claim
  fhir:ClaimResponse.request [ Reference(Claim) ]; # 0..1 Id of resource triggering adjudication
  fhir:ClaimResponse.outcome [ code ]; # 1..1 queued | complete | error | partial
  fhir:ClaimResponse.disposition [ string ]; # 0..1 Disposition Message
  fhir:ClaimResponse.preAuthRef [ string ]; # 0..1 Preauthorization reference
  fhir:ClaimResponse.preAuthPeriod [ Period ]; # 0..1 Preauthorization reference effective period
  fhir:ClaimResponse.payeeType [ CodeableConcept ]; # 0..1 Party to be paid any benefits payable
  fhir:ClaimResponse.item [ # 0..* Adjudication for claim line items
    fhir:ClaimResponse.item.itemSequence [ positiveInt ]; # 1..1 Claim item instance identifier
    fhir:ClaimResponse.item.noteNumber [ positiveInt ], ... ; # 0..* Applicable note numbers
    fhir:ClaimResponse.item.adjudication [ # 1..* Adjudication details
      fhir:ClaimResponse.item.adjudication.category [ CodeableConcept ]; # 1..1 Type of adjudication information
      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:
      fhir:
      fhir:
      fhir:
      fhir:
        fhir:
        fhir:
        fhir:

    fhir:ClaimResponse.item.detail [ # 0..* Adjudication for claim details
      fhir:ClaimResponse.item.detail.detailSequence [ positiveInt ]; # 1..1 Claim detail instance identifier
      fhir:ClaimResponse.item.detail.noteNumber [ positiveInt ], ... ; # 0..* Applicable note numbers
      fhir:ClaimResponse.item.detail.adjudication [ See ClaimResponse.item.adjudication ], ... ; # 1..* Detail level adjudication details
      fhir:ClaimResponse.item.detail.subDetail [ # 0..* Adjudication for claim sub-details
        fhir:ClaimResponse.item.detail.subDetail.subDetailSequence [ positiveInt ]; # 1..1 Claim sub-detail instance identifier
        fhir:ClaimResponse.item.detail.subDetail.noteNumber [ positiveInt ], ... ; # 0..* Applicable note numbers
        fhir:ClaimResponse.item.detail.subDetail.adjudication [ See ClaimResponse.item.adjudication ], ... ; # 0..* Subdetail level adjudication details

      ], ...;
    ], ...;
  ], ...;
  fhir:
    fhir:
    fhir:
    fhir:
    fhir:
    fhir:
    fhir:
    fhir:
    fhir:
  ], ...;
  fhir:
    fhir:
    fhir:
    fhir:
    fhir:

  fhir:ClaimResponse.addItem [ # 0..* Insurer added line items
    fhir:ClaimResponse.addItem.itemSequence [ positiveInt ], ... ; # 0..* Item sequence number
    fhir:ClaimResponse.addItem.detailSequence [ positiveInt ], ... ; # 0..* Detail sequence number
    fhir:ClaimResponse.addItem.subdetailSequence [ positiveInt ], ... ; # 0..* Subdetail sequence number
    fhir:ClaimResponse.addItem.provider [ Reference(Organization|Practitioner|PractitionerRole) ], ... ; # 0..* Authorized providers
    fhir:ClaimResponse.addItem.productOrService [ CodeableConcept ]; # 1..1 Billing, service, product, or drug code
    fhir:ClaimResponse.addItem.modifier [ CodeableConcept ], ... ; # 0..* Service/Product billing modifiers
    fhir:ClaimResponse.addItem.programCode [ CodeableConcept ], ... ; # 0..* Program the product or service is provided under
    # ClaimResponse.addItem.serviced[x] : 0..1 Date or dates of service or product delivery. One of these 2
      fhir:ClaimResponse.addItem.servicedDate [ date ]
      fhir:ClaimResponse.addItem.servicedPeriod [ Period ]
    # ClaimResponse.addItem.location[x] : 0..1 Place of service or where product was supplied. One of these 3
      fhir:ClaimResponse.addItem.locationCodeableConcept [ CodeableConcept ]
      fhir:ClaimResponse.addItem.locationAddress [ Address ]
      fhir:ClaimResponse.addItem.locationReference [ Reference(Location) ]
    fhir:ClaimResponse.addItem.quantity [ Quantity(SimpleQuantity) ]; # 0..1 Count of products or services
    fhir:ClaimResponse.addItem.unitPrice [ Money ]; # 0..1 Fee, charge or cost per item
    fhir:ClaimResponse.addItem.factor [ decimal ]; # 0..1 Price scaling factor
    fhir:ClaimResponse.addItem.net [ Money ]; # 0..1 Total item cost
    fhir:ClaimResponse.addItem.bodySite [ CodeableConcept ]; # 0..1 Anatomical location
    fhir:ClaimResponse.addItem.subSite [ CodeableConcept ], ... ; # 0..* Anatomical sub-location
    fhir:ClaimResponse.addItem.noteNumber [ positiveInt ], ... ; # 0..* Applicable note numbers
    fhir:ClaimResponse.addItem.adjudication [ See ClaimResponse.item.adjudication ], ... ; # 1..* Added items adjudication
    fhir:ClaimResponse.addItem.detail [ # 0..* Insurer added line details
      fhir:ClaimResponse.addItem.detail.productOrService [ CodeableConcept ]; # 1..1 Billing, service, product, or drug code
      fhir:ClaimResponse.addItem.detail.modifier [ CodeableConcept ], ... ; # 0..* Service/Product billing modifiers
      fhir:ClaimResponse.addItem.detail.quantity [ Quantity(SimpleQuantity) ]; # 0..1 Count of products or services
      fhir:ClaimResponse.addItem.detail.unitPrice [ Money ]; # 0..1 Fee, charge or cost per item
      fhir:ClaimResponse.addItem.detail.factor [ decimal ]; # 0..1 Price scaling factor
      fhir:ClaimResponse.addItem.detail.net [ Money ]; # 0..1 Total item cost
      fhir:ClaimResponse.addItem.detail.noteNumber [ positiveInt ], ... ; # 0..* Applicable note numbers
      fhir:ClaimResponse.addItem.detail.adjudication [ See ClaimResponse.item.adjudication ], ... ; # 1..* Added items detail adjudication
      fhir:ClaimResponse.addItem.detail.subDetail [ # 0..* Insurer added line items
        fhir:ClaimResponse.addItem.detail.subDetail.productOrService [ CodeableConcept ]; # 1..1 Billing, service, product, or drug code
        fhir:ClaimResponse.addItem.detail.subDetail.modifier [ CodeableConcept ], ... ; # 0..* Service/Product billing modifiers
        fhir:ClaimResponse.addItem.detail.subDetail.quantity [ Quantity(SimpleQuantity) ]; # 0..1 Count of products or services
        fhir:ClaimResponse.addItem.detail.subDetail.unitPrice [ Money ]; # 0..1 Fee, charge or cost per item
        fhir:ClaimResponse.addItem.detail.subDetail.factor [ decimal ]; # 0..1 Price scaling factor
        fhir:ClaimResponse.addItem.detail.subDetail.net [ Money ]; # 0..1 Total item cost
        fhir:ClaimResponse.addItem.detail.subDetail.noteNumber [ positiveInt ], ... ; # 0..* Applicable note numbers
        fhir:ClaimResponse.addItem.detail.subDetail.adjudication [ See ClaimResponse.item.adjudication ], ... ; # 1..* Added items detail adjudication
      ], ...;
    ], ...;

  ], ...;
  fhir:
    fhir:
    fhir:

  fhir:ClaimResponse.adjudication [ See ClaimResponse.item.adjudication ], ... ; # 0..* Header-level adjudication
  fhir:ClaimResponse.total [ # 0..* Adjudication totals
    fhir:ClaimResponse.total.category [ CodeableConcept ]; # 1..1 Type of adjudication information
    fhir:ClaimResponse.total.amount [ Money ]; # 1..1 Financial total for the category

  ], ...;
  fhir:
    fhir:
    fhir:
    fhir:
    fhir:
    fhir:
    fhir:

  fhir:ClaimResponse.payment [ # 0..1 Payment Details
    fhir:ClaimResponse.payment.type [ CodeableConcept ]; # 1..1 Partial or complete payment
    fhir:ClaimResponse.payment.adjustment [ Money ]; # 0..1 Payment adjustment for non-claim issues
    fhir:ClaimResponse.payment.adjustmentReason [ CodeableConcept ]; # 0..1 Explanation for the adjustment
    fhir:ClaimResponse.payment.date [ date ]; # 0..1 Expected date of payment
    fhir:ClaimResponse.payment.amount [ Money ]; # 1..1 Payable amount after adjustment
    fhir:ClaimResponse.payment.identifier [ Identifier ]; # 0..1 Business identifier for the payment

  ];
  fhir:
  fhir:
  fhir:
    fhir:
    fhir:
    fhir:
    fhir:

  fhir:ClaimResponse.fundsReserve [ CodeableConcept ]; # 0..1 Funds reserved status
  fhir:ClaimResponse.formCode [ CodeableConcept ]; # 0..1 Printed form identifier
  fhir:ClaimResponse.form [ Attachment ]; # 0..1 Printed reference or actual form
  fhir:ClaimResponse.processNote [ # 0..* Note concerning adjudication
    fhir:ClaimResponse.processNote.number [ positiveInt ]; # 0..1 Note instance identifier
    fhir:ClaimResponse.processNote.type [ code ]; # 0..1 display | print | printoper
    fhir:ClaimResponse.processNote.text [ string ]; # 1..1 Note explanatory text
    fhir:ClaimResponse.processNote.language [ CodeableConcept ]; # 0..1 Language of the text

  ], ...;
  fhir:
  fhir:
    fhir:
    fhir:
    fhir:
    fhir:
    fhir:
    fhir:

  fhir:ClaimResponse.communicationRequest [ Reference(CommunicationRequest) ], ... ; # 0..* Request for additional information
  fhir:ClaimResponse.insurance [ # 0..* Patient insurance information
    fhir:ClaimResponse.insurance.sequence [ positiveInt ]; # 1..1 Insurance instance identifier
    fhir:ClaimResponse.insurance.focal [ boolean ]; # 1..1 Coverage to be used for adjudication
    fhir:ClaimResponse.insurance.coverage [ Reference(Coverage) ]; # 1..1 Insurance information
    fhir:ClaimResponse.insurance.businessArrangement [ string ]; # 0..1 Additional provider contract number
    fhir:ClaimResponse.insurance.claimResponse [ Reference(ClaimResponse) ]; # 0..1 Adjudication results
  ], ...;
  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

  ], ...;
]

Changes since DSTU2 Release 3

ClaimResponse.type Added Element ClaimResponse.subType Added Element
ClaimResponse
ClaimResponse.use ClaimResponse.status
  • Added Element Change value set from http://hl7.org/fhir/ValueSet/fm-status|4.0.0 to http://hl7.org/fhir/ValueSet/fm-status|4.1.0
ClaimResponse.requestProvider ClaimResponse.use
  • Type changed Change value set from Reference(Practitioner) http://hl7.org/fhir/ValueSet/claim-use|4.0.0 to Reference(Practitioner|PractitionerRole|Organization) http://hl7.org/fhir/ValueSet/claim-use|4.1.0
ClaimResponse.outcome
  • Type changed Change value set from CodeableConcept http://hl7.org/fhir/ValueSet/remittance-outcome|4.0.0 to code Add Binding http://hl7.org/fhir/ValueSet/remittance-outcome (required) ClaimResponse.item.itemSequence Added Element ClaimResponse.item.detail.detailSequence Added Element ClaimResponse.item.detail.subDetail.subDetailSequence Added Element ClaimResponse.addItem.itemSequence Added Element ClaimResponse.addItem.detailSequence Added Element ClaimResponse.addItem.subdetailSequence Added Element ClaimResponse.error.itemSequence Added Element ClaimResponse.error.detailSequence Added Element ClaimResponse.error.subDetailSequence Added Element ClaimResponse.total Added Element ClaimResponse.total.category Added Element ClaimResponse.total.amount Added Element http://hl7.org/fhir/ValueSet/remittance-outcome|4.1.0
ClaimResponse.processNote.type
  • Type changed Change value set from CodeableConcept http://hl7.org/fhir/ValueSet/note-type|4.0.0 to code ClaimResponse.requestOrganization deleted ClaimResponse.item.sequenceLinkId deleted ClaimResponse.item.detail.sequenceLinkId deleted ClaimResponse.item.detail.subDetail.sequenceLinkId deleted ClaimResponse.addItem.sequenceLinkId deleted ClaimResponse.addItem.revenue deleted ClaimResponse.addItem.category deleted ClaimResponse.addItem.detail deleted ClaimResponse.error.sequenceLinkId deleted ClaimResponse.error.detailSequenceLinkId deleted ClaimResponse.error.subdetailSequenceLinkId deleted ClaimResponse.totalCost deleted ClaimResponse.unallocDeductable deleted ClaimResponse.totalBenefit deleted http://hl7.org/fhir/ValueSet/note-type|4.1.0

See the Full Difference for further information

This analysis is available as XML or JSON .

See R3 <--> R4 Conversion Maps (status = 1 test that all execute ok. 1 fail round-trip testing and 1 r3 resources are invalid (0 errors). )

 

Alternate See the Profiles & Extensions and the alternate definitions: Master Definition XML + JSON , XML Schema / Schematron + JSON Schema , ShEx (for Turtle ) + see the extensions , the spreadsheet version & the dependency analysis a

ClaimResponse.error.code ClaimResponse.reserved ClaimResponse.form
Path Definition Type Reference
ClaimResponse.status A code specifying the state of the resource instance. Required Financial Resource Status Codes FinancialResourceStatusCodes
ClaimResponse.type The type or discipline-style of the claim claim. Extensible Claim Type Codes ClaimTypeCodes
ClaimResponse.subType A more granulat granular claim typecode typecode. Example Example Claim SubType Codes ExampleClaimSubTypeCodes
ClaimResponse.use Complete, proposed, exploratory, other Claim, preauthorization, predetermination. Required Use
ClaimResponse.outcome The result of the claim processing processing. Required Claim Processing Codes ClaimProcessingCodes
ClaimResponse.payeeType A code for the party to be reimbursed. Example Claim Payee Type Codes
ClaimResponse.item.adjudication.category
ClaimResponse.total.category
The adjudication codes. Example Adjudication Value Codes AdjudicationValueCodes
ClaimResponse.item.adjudication.reason The adjudication reason codes. Example Adjudication Reason Codes AdjudicationReasonCodes
ClaimResponse.addItem.service ClaimResponse.addItem.productOrService
ClaimResponse.addItem.detail.productOrService
ClaimResponse.addItem.detail.subDetail.productOrService
Allowable service and product codes. Example USCLS Codes USCLSCodes
ClaimResponse.addItem.modifier
ClaimResponse.addItem.detail.modifier
ClaimResponse.addItem.detail.subDetail.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. Example Modifier type Codes ModifierTypeCodes
ClaimResponse.addItem.programCode The adjudication error Program specific reason codes. Example Adjudication Error Codes ExampleProgramReasonCodes
ClaimResponse.addItem.location[x] Place of service: pharmacy, school, prison, etc. Example ExampleServicePlaceCodes
ClaimResponse.addItem.bodySite The code for the teeth, quadrant, sextant and arch. Example OralSiteCodes
ClaimResponse.addItem.subSite The code for the tooth surface and surface combinations. Example SurfaceCodes
ClaimResponse.payment.type The type (partial, complete) of the payment payment. Example Example Payment Type Codes ExamplePaymentTypeCodes
ClaimResponse.payment.adjustmentReason Payment Adjustment reason codes. Example Payment Adjustment Reason Codes PaymentAdjustmentReasonCodes
ClaimResponse.fundsReserve For whom funds are to be reserved: (Patient, Provider, None). Example Funds Reservation Codes
ClaimResponse.formCode The forms codes. Example Form Codes
ClaimResponse.processNote.type The presentation types of notes. Required NoteType
ClaimResponse.processNote.language A human language. Extensible Preferred , but limited to All Languages AllLanguages Common Languages CommonLanguages
ClaimResponse.error.code The adjudication error codes. Example Adjudication Error Codes

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

Name Type Description Expression In Common
created date The creation date ClaimResponse.created
disposition string The contents of the disposition message ClaimResponse.disposition
identifier token The identity of the claimresponse ClaimResponse ClaimResponse.identifier
insurer reference The organization who which generated this resource ClaimResponse.insurer
( Organization )
outcome token The processing outcome ClaimResponse.outcome
patient reference The subject of care. care ClaimResponse.patient
( Patient )
payment-date date The expected paymentDate payment date ClaimResponse.payment.date
request reference The claim reference ClaimResponse.request
( Claim )
request-provider requestor reference The Provider of the claim ClaimResponse.requestProvider ClaimResponse.requestor
( Practitioner , Organization , PractitionerRole )
status token The status of the claim response ClaimResponse ClaimResponse.status
use token The type of claim ClaimResponse.use