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

The Response business identifier. The Response business identifier.

Original request resource referrence. Original request resource referrence.

The version of the style of resource contents. This should be mapped to the allowable profiles for this and supporting resources. The version of the style of resource contents. This should be mapped to the allowable profiles for this and supporting resources.

The style (standard) and version of the original material which was converted into this resource. The style (standard) and version of the original material which was converted into this resource.

Knowledge of the original version can inform the processing of this instance so that information which is processable by the originating system may be generated. Knowledge of the original version can inform the processing of this instance so that information which is processable by the originating system may be generated.

The date when the enclosed suite of services were performed or completed. The date when the enclosed suite of services were performed or completed.

The Insurer who produced this adjudicated response. The Insurer who produced this adjudicated response.

The practitioner who is responsible for the services rendered to the patient. The practitioner who is responsible for the services rendered to the patient.

The organization which is responsible for the services rendered to the patient. The organization which is responsible for the services rendered to the patient.

Transaction status: error, complete. Transaction status: error, complete.

A description of the status of the adjudication. A description of the status of the adjudication.

Party to be reimbursed: Subscriber, provider, other. Party to be reimbursed: Subscriber, provider, other.

The first tier service adjudications for submitted services. The first tier service adjudications for submitted services.

A service line number. A service line number.

A list of note references to the notes provided below. A list of note references to the notes provided below.

The adjudications results. The adjudications results.

Code indicating: Co-Pay, deductible, eligible, benefit, tax, etc. Code indicating: Co-Pay, deductible, eligible, benefit, tax, etc.

Adjudication reason such as limit reached.

Monetary amount associated with the code. Monetary amount associated with the code.

A non-monetary value for example a percentage. Mutually exclusive to the amount element above. A non-monetary value for example a percentage. Mutually exclusive to the amount element above.

The second tier service adjudications for submitted services. The second tier service adjudications for submitted services.

A service line number. A service line number.

The adjudications results. The adjudications results.

Code indicating: Co-Pay, deductible, eligible, benefit, tax, etc. Code indicating: Co-Pay, deductible, eligible, benefit, tax, etc.

Adjudication reason such as limit reached.

Monetary amount associated with the code. Monetary amount associated with the code.

A non-monetary value for example a percentage. Mutually exclusive to the amount element above. A non-monetary value for example a percentage. Mutually exclusive to the amount element above.

The third tier service adjudications for submitted services. The third tier service adjudications for submitted services.

A service line number. A service line number.

The adjudications results. The adjudications results.

Code indicating: Co-Pay, deductible, eligible, benefit, tax, etc. Code indicating: Co-Pay, deductible, eligible, benefit, tax, etc.

Adjudication reason such as limit reached.

Monetary amount associated with the code. Monetary amount associated with the code.

A non-monetary value for example a percentage. Mutually exclusive to the amount element above. A non-monetary value for example a percentage. Mutually exclusive to the amount element above.

The first tier service adjudications for payor added services. The first tier service adjudications for payor added services.

List of input service items which this service line is intended to replace. List of input service items which this service line is intended to replace.

A code to indicate the Professional Service or Product supplied. A code to indicate the Professional Service or Product supplied.

The fee charged for the professional service or product.. The fee charged for the professional service or product..

A list of note references to the notes provided below. A list of note references to the notes provided below.

The adjudications results. The adjudications results.

Code indicating: Co-Pay, deductible, eligible, benefit, tax, etc. Code indicating: Co-Pay, deductible, eligible, benefit, tax, etc.

Adjudication reason such as limit reached.

Monetary amount associated with the code. Monetary amount associated with the code.

A non-monetary value for example a percentage. Mutually exclusive to the amount element above. A non-monetary value for example a percentage. Mutually exclusive to the amount element above.

The second tier service adjudications for payor added services. The second tier service adjudications for payor added services.

A code to indicate the Professional Service or Product supplied. A code to indicate the Professional Service or Product supplied.

The fee charged for the professional service or product.. The fee charged for the professional service or product..

The adjudications results. The adjudications results.

Code indicating: Co-Pay, deductible, eligible, benefit, tax, etc. Code indicating: Co-Pay, deductible, eligible, benefit, tax, etc.

Adjudication reason such as limit reached.

Monetary amount associated with the code. Monetary amount associated with the code.

A non-monetary value for example a percentage. Mutually exclusive to the amount element above. A non-monetary value for example a percentage. Mutually exclusive to the amount element above.

Mutually exclusive with Services Provided (Item). Mutually exclusive with Services Provided (Item).

The sequence number of the line item submitted which contains the error. This value is omitted when the error is elsewhere. The sequence number of the line item submitted which contains the error. This value is omitted when the error is elsewhere.

The sequence number of the addition within the line item submitted which contains the error. This value is omitted when the error is not related to an Addition. The sequence number of the addition within the line item submitted which contains the error. This value is omitted when the error is not related to an Addition.

The sequence number of the addition within the line item submitted which contains the error. This value is omitted when the error is not related to an Addition. The sequence number of the addition within the line item submitted which contains the error. This value is omitted when the error is not related to an Addition.

An error code,froma specified code system, which details why the claim could not be adjudicated. An error code,from a specified code system, which details why the claim could not be adjudicated.

The total cost of the services reported. The total cost of the services reported.

This is a check value that the receiver calculates and returns. This is a check value that the receiver calculates and returns.

The amount of deductible applied which was not allocated to any particular service line. The amount of deductible applied which was not allocated to any particular service line.

Total amount of benefit payable (Equal to sum of the Benefit amounts from all detail lines and additions less the Unallocated Deductible). Total amount of benefit payable (Equal to sum of the Benefit amounts from all detail lines and additions less the Unallocated Deductible).

Adjustment to the payment of this transaction which is not related to adjudication of this transaction. Adjustment to the payment of this transaction which is not related to adjudication of this transaction.

Reason for the payment adjustment. Reason for the payment adjustment.

Estimated payment data. Estimated payment data.

Payable less any payment adjustment. Payable less any payment adjustment.

Payment identifier. Payment identifier.

Status of funds reservation (For provider, for Patient, None). Status of funds reservation (For provider, for Patient, None).

The form to be used for printing the content. The form to be used for printing the content.

Note text. Note text.

An integer associated with each note which may be referred to from each service line item. An integer associated with each note which may be referred to from each service line item.

The note purpose: Print/Display. The note purpose: Print/Display.

The note text. The note text.

Financial instrument by which payment information for health care. Financial instrument by which payment information for health care.

Health care programs and insurers are significant payors of health service costs. Health care programs and insurers are significant payors of health service costs.

A service line item. A service line item.

To maintain order of the coverages. To maintain order of the coverages.

The instance number of the Coverage which is the focus for adjudication. The Coverage against which the claim is to be adjudicated. The instance number of the Coverage which is the focus for adjudication. The Coverage against which the claim is to be adjudicated.

To identify which coverage is being adjudicated. To identify which coverage is being adjudicated.

Reference to the program or plan identification, underwriter or payor. Reference to the program or plan identification, underwriter or payor.

The contract number of a business agreement which describes the terms and conditions. Control 0..1 Type string Need to identify the issuer to target for processing and for coordination of benefit processing.

The relationship of the patient to the subscriber. The contract number of a business agreement which describes the terms and conditions.

A list of references from the Insurer to which these services pertain. A list of references from the Insurer to which these services pertain.

To provide any pre-determination or prior authorization reference. To provide any pre-determination or prior authorization reference.

The Coverages adjudication details. The Coverages adjudication details.

Knowledge of the original version can inform the processing of this instance so that information which is processable by the originating system may be generated. Used by downstream payers to determine what balance remains and the net payable.