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.

The status of the resource instance.

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. Processing outcome errror, partial or complete processing.

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.

Monetary amount associated with the code. Adjudication reason such as limit reached.

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

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

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

Code indicating: Co-Pay, deductible, eligible, benefit, tax, etc. A service line number.

Monetary amount associated with the code. A list of note references to the notes provided below.

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

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

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

The first tier service adjudications for payor added services.

Monetary amount associated with the code. List of input service items which this service line is intended to replace.

A non-monetary value for example a percentage. Mutually exclusive to the amount element above. The type of reveneu or cost center providing the product and/or service.

The first tier service adjudications for payor added services. Health Care Service Type Codes to identify the classification of service or benefits.

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. Item typification or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or for medical whether the treatment was outside the clinic or out of office hours.

May impact on adjudication.

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. The second tier service adjudications for payor added services.

Monetary amount associated with the code. The type of reveneu or cost center providing the product and/or service.

A non-monetary value for example a percentage. Mutually exclusive to the amount element above. Health Care Service Type Codes to identify the classification of service or benefits.

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. Item typification or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or for medical whether the treatment was outside the clinic or out of office hours.

May impact on adjudication.

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

The adjudications results. A list of note references to the notes provided below.

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

Monetary amount associated with the code. Mutually exclusive with Services Provided (Item).

A non-monetary value for example a percentage. Mutually exclusive to the amount element above. The sequence number of the line item submitted which contains the error. This value is omitted when the error is elsewhere.

Mutually exclusive with Services Provided (Item). 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 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. An error code,from a specified code system, which details why the claim could not be adjudicated.

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 total cost of the services reported.

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

An error code,froma specified code system, which details why the claim could not be adjudicated. The amount of deductible applied which was not allocated to any particular service line.

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

The amount of deductible applied which was not allocated to any particular service line. Payment details for the claim if the claim has been paid.

Total amount of benefit payable (Equal to sum of the Benefit amounts from all detail lines and additions less the Unallocated Deductible). Whether this represents partial or complete payment of the claim.

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. The ISO-639-1 alpha 2 code in lower case for the language, optionally followed by a hyphen and the ISO-3166-1 alpha 2 code for the region in upper case; e.g. "en" for English, or "en-US" for American English versus "en-EN" for England English.

The instance number of the Coverage which is the focus for adjudication. The Coverage against which the claim is to be adjudicated. Financial instrument by which payment information for health care.

To identify which coverage is being adjudicated. Summary true Health care programs and insurers are significant payors of health service costs.

Reference to the program or plan identification, underwriter or payor. A service line item.

Need to identify the issuer to target for processing and for coordination of benefit processing. Summary true To maintain order of the coverages.

The contract number of a business agreement which describes the terms and conditions. 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.

The relationship of the patient to the subscriber. Reference to the program or plan identification, underwriter or payor.

To determine the relationship between the patient and the subscriber. Summary true Need to identify the issuer to target for processing and for coordination of benefit processing.

A list of references from the Insurer to which these services pertain. The contract number of a business agreement which describes the terms and conditions.

The Coverages adjudication details. A list of references from the Insurer to which these services pertain.

Used by downstream payers to determine what balance remains and the net payable. Summary true To provide any pre-determination or prior authorization reference.

The style (standard) and version of the original material which was converted into this resource. 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. Summary true © HL7.org 2011+. FHIR DSTU2 (v1.0.2-7202) generated on Sat, Oct 24, 2015 07:43+1100. Links: Search Used by downstream payers to determine what balance remains and the net payable.