FHIR Release 3 (STU) R4 Ballot #2 (Mixed Normative/Trial use)

This page is part of the FHIR Specification (v3.0.2: STU 3). (v3.5.0: R4 Ballot #2). The current version which supercedes this version is 5.0.0 . For a full list of available versions, see the Directory of published versions . Page versions: R5 R4B R4 R3 R2

13.7 Resource ClaimResponse - Content

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

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

13.7.1 Scope and Usage

The ClaimResponse resource provides application level error 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 or a Pre-Authorization.

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

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

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

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

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

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

13.7.2 Resource Content

Structure

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

doco Documentation for this format

UML Diagram ( Legend )

ClaimResponse ( DomainResource ) The Response response business identifier identifier : Identifier [0..*] The status of the resource instance (this element modifies the meaning of other elements) status : code [0..1] « A code specifying the state of the resource instance. (Strength=Required) Financial Resource Status FinancialResourceStatusCodes ! » The category of claim, e.g, oral, pharmacy, vision, institutional, professional type : CodeableConcept [0..1] « The type or discipline-style of the claim. (Strength=Extensible) ClaimTypeCodes + » A finer grained suite of claim subtype codes which may convey Inpatient vs Outpatient and/or a specialty service. In the US the CMS Bill Type subType : CodeableConcept [0..1] « A more granulat claim typecode. (Strength=Example) ExampleClaimSubTypeCodes ?? » A claim, a list of completed goods and services; a preauthorization, a list or proposed goods and services; or a predetermination, a set of goods and services being considered, for which insurer adjudication is sought use : code [0..1] « Claim, preauthorization, predetermination. (Strength=Required) Use ! » Patient Resource patient : Reference [0..1] « Patient » The date when the enclosed suite of services were performed or completed this resource was created created : dateTime [0..1] The Insurer who produced this adjudicated response insurer : Reference [0..1] « Organization » The practitioner who is responsible for the services rendered to the patient requestProvider : Reference [0..1] « Practitioner | PractitionerRole | The organization which is responsible for the services rendered to the patient requestOrganization : Reference [0..1] Organization » Original request resource referrence reference request : Reference [0..1] « Claim » Processing outcome errror, Transaction: error, complete, partial or complete processing outcome : CodeableConcept code [0..1] « The result of the claim processing (Strength=Example) processing. (Strength=Required) Claim Processing ?? ClaimProcessingCodes ! » A description of the status of the adjudication disposition : string [0..1] A list of references from the Insurer to which these services pertain preAuthRef : string [0..1] Party to be reimbursed: Subscriber, provider, other payeeType : CodeableConcept [0..1] « A code for the party to be reimbursed. (Strength=Example) Claim Payee Type ?? » The total cost of the services reported totalCost : Money [0..1] The amount of deductible applied which was not allocated to any particular service line unallocDeductable : Money [0..1] Total amount of benefit payable (Equal to sum of the Benefit amounts from all detail lines and additions less the Unallocated Deductible) totalBenefit : Money [0..1] Status of funds reservation (For provider, for Patient, None) reserved : Coding [0..1] « For whom funds are to be reserved: (Patient, Provider, None). (Strength=Example) Funds Reservation ?? » The form to be used for printing the content form : CodeableConcept [0..1] « The forms codes. (Strength=Example) Form ?? » Request for additional supporting or authorizing information, such as: documents, images or resources communicationRequest : Reference [0..*] « CommunicationRequest » Item A service line number sequenceLinkId itemSequence : positiveInt [1..1] A list of note references to the notes provided below noteNumber : positiveInt [0..*] Adjudication Code indicating: Co-Pay, deductible, eligible, benefit, tax, etc category : CodeableConcept [1..1] « The adjudication codes. (Strength=Example) Adjudication Value AdjudicationValueCodes ?? » Adjudication reason such as limit reached reason : CodeableConcept [0..1] « The adjudication reason codes. (Strength=Example) Adjudication Reason AdjudicationReasonCodes ?? » Monetary amount associated with the code amount : Money [0..1] A non-monetary value for example a percentage. Mutually exclusive to the amount element above value : decimal [0..1] ItemDetail A service line number sequenceLinkId detailSequence : positiveInt [1..1] A list of note references to the notes provided below noteNumber : positiveInt [0..*] SubDetail A service line number sequenceLinkId subDetailSequence : positiveInt [1..1] A list of note references to the notes provided below noteNumber : positiveInt [0..*] AddedItem List of input service items which this service line is intended to replace sequenceLinkId itemSequence : positiveInt [0..*] The type sequence number of reveneu or cost center providing the product and/or service addition within the line item submitted which contains the error. This value is omitted when the error is not related to an Addition revenue detailSequence : CodeableConcept positiveInt [0..1] [0..*] Codes for The sequence number of the revenue or cost centers supplying addition within the service and/or products. (Strength=Example) line item submitted which contains the error. This value is omitted when the error is not related to an Addition Example Revenue Center subdetailSequence ?? : positiveInt [0..*] Health Care Service Type Codes The providers who are authorized for the services rendered to identify the classification of service or benefits patient category provider : CodeableConcept Reference [0..1] [0..*] « Practitioner | PractitionerRole | Benefit subcategories such as: oral-basic, major, glasses (Strength=Example) Benefit SubCategory Organization ?? » A code to indicate the Professional Service or Product supplied service billcode : CodeableConcept [0..1] « Allowable service and product codes. (Strength=Example) USCLS USCLSCodes ?? » Item typification or modifiers codes, eg e.g. 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 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 ?? » For programs which require reason codes for the inclusion or covering of this billed item under the program or sub-program programCode : CodeableConcept [0..*] « Program specific reason codes. (Strength=Example) ExampleProgramReasonCodes ?? » The date or dates when the service or product was supplied, performed or completed serviced[x] : Type [0..1] « date | Period » Where the service was provided location[x] : Type [0..1] « CodeableConcept | Address | Reference ( Location ); Place of service: pharmacy,school, prison, etc. (Strength=Example) ExampleServicePlaceCodes ?? » The number of repetitions of a service or product quantity : Quantity ( SimpleQuantity ) [0..1] If the item is a node then this is the fee charged for the professional product or service, otherwise this is the total of the fees for the children 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. product or charge. For example, the formula: unit Quantity * unit Price (Cost per Point) * factor Number * points = net Amount. Quantity, factor and points are assumed to be 1 if not supplied fee 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 site, e.g. limb region or tooth surface(s) subSite : CodeableConcept [0..*] « The code for the tooth surface and surface combinations. (Strength=Example) SurfaceCodes ?? » A list of note references to the notes provided below noteNumber : positiveInt [0..*] AddedItemsDetail AddedItemDetail The type of reveneu or cost center providing A code to indicate the product and/or service Professional Service or Product supplied revenue billcode : CodeableConcept [0..1] « Allowable service and product codes. (Strength=Example) USCLSCodes ?? » Codes Item typification or modifiers codes, e.g. for Oral whether the revenue treatment is cosmetic or cost centers supplying associated with TMJ, or for medical whether the service and/or products. treatment was outside the clinic or out of office hours 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) Example Revenue Center ModifierTypeCodes ?? » Health Care Service Type Codes to identify The number of repetitions of a service or product quantity : Quantity ( SimpleQuantity ) [0..1] If the classification item is a node then this is the fee for the product or service, otherwise this is the total of the fees for the children 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 benefits product or charge. For example, the formula: unit Quantity * unit Price (Cost per Point) * factor Number * points = net Amount. Quantity, factor and points are assumed to be 1 if not supplied category net : CodeableConcept Money [0..1] Benefit subcategories such as: oral-basic, major, glasses (Strength=Example) A list of note references to the notes provided below Benefit SubCategory noteNumber ?? : positiveInt [0..*] AddedItemSubDetail A code to indicate the Professional Service or Product supplied service billcode : CodeableConcept [0..1] « Allowable service and product codes. (Strength=Example) USCLS USCLSCodes ?? » Item typification or modifiers codes, eg e.g. 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 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 a node then this is the fee charged for the professional product or service, otherwise this is the total of the fees for the children 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. product or charge. For example, the formula: unit Quantity * unit Price (Cost per Point) * factor Number * points = net Amount. Quantity, factor and points are assumed to be 1 if not supplied fee net : Money [0..1] A list of note references to the notes provided below noteNumber : positiveInt [0..*] Error The sequence number of the line item submitted which contains the error. This value is omitted when the error is elsewhere sequenceLinkId itemSequence : positiveInt [0..1] The sequence number of the addition within the line item submitted which contains the error. This value is omitted when the error is not related to an Addition detailSequenceLinkId detailSequence : positiveInt [0..1] The sequence number of the addition within the line item submitted which contains the error. This value is omitted when the error is not related to an Addition subdetailSequenceLinkId subDetailSequence : positiveInt [0..1] An error code,from code, from a specified code system, which details why the claim could not be adjudicated code : CodeableConcept [1..1] « The adjudication error codes. (Strength=Example) Adjudication Error ?? » Total Code indicating: Submitted, Co-Pay, deductible, eligible, benefit, tax, etc category : CodeableConcept [1..1] « The adjudication codes. (Strength=Example) AdjudicationValueCodes ?? » Monitory amount associated with the code amount : Money [1..1] Payment Whether this represents partial or complete payment of the claim type : CodeableConcept [0..1] « The type (partial, complete) of the payment payment. (Strength=Example) Example Payment Type ExamplePaymentTypeCodes ?? » Adjustment to the payment of this transaction which is not related to adjudication of this transaction adjustment : Money [0..1] Reason for the payment adjustment adjustmentReason : CodeableConcept [0..1] « Payment Adjustment reason codes. (Strength=Example) Payment Adjustment Reason PaymentAdjustmentReasonCodes ?? » Estimated payment data date : date [0..1] Payable less any payment adjustment amount : Money [0..1] Payment identifier identifier : Identifier [0..1] Note An integer associated with each note which may be referred to from each service line item number : positiveInt [0..1] The note purpose: Print/Display type : CodeableConcept code [0..1] « The presentation types of notes. (Strength=Required) NoteType ! » The note text text : string [0..1] The ISO-639-1 alpha 2 code in lower case for the language, optionally followed by a hyphen and the ISO-3166-1 alpha 2 code for the region in upper case; e.g. "en" "en" for English, or "en-US" "en-US" for American English versus "en-EN" "en-EN" for England English language : CodeableConcept [0..1] « A human language. (Strength=Extensible) (Strength=Preferred) Common Languages + ? » Insurance A service line item sequence : positiveInt [1..1] The instance number of the Coverage which is the focus for adjudication. The Coverage against which the claim is to be adjudicated focal : boolean [1..1] Reference to the program or plan identification, underwriter or payor coverage : Reference [1..1] « Coverage » The contract number of a business agreement which describes the terms and conditions businessArrangement : string [0..1] A list of references from the Insurer to which these services pertain preAuthRef : string [0..*] The Coverages adjudication details claimResponse : Reference [0..1] « ClaimResponse » The adjudication results adjudication [0..*] The adjudications adjudication results adjudication [0..*] The adjudications adjudication results adjudication [0..*] The third tier third-tier service adjudications for submitted services subDetail [0..*] The second tier second-tier service adjudications for submitted services detail [0..*] The first tier first-tier service adjudications for submitted services item [0..*] The adjudications adjudication results adjudication [0..*] The adjudications adjudication results adjudication [0..*] The second tier adjudication results adjudication [0..*] The third-tier service adjudications for payor added services subDetail [0..*] The second-tier service adjudications for payor added services detail [0..*] The first tier first-tier service adjudications for payor added services addItem [0..*] Mutually exclusive with Services Provided (Item) error [0..*] Totals for amounts submitted, co-pays, benefits payable etc total [0..*] Payment details for the claim if the claim has been paid payment [0..1] Note text processNote [0..*] Financial instrument by which payment information for health care insurance [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>
 <

 <identifier><!-- 0..* Identifier Response  number --></identifier>
 <status value="[code]"/><!-- 0..1 active | cancelled | draft | entered-in-error -->
 <type><!-- 0..1 CodeableConcept Type or discipline --></type>
 <subType><!-- 0..1 CodeableConcept Finer grained claim type information --></subType>
 <use value="[code]"/><!-- 0..1 claim | preauthorization | predetermination -->

 <patient><!-- 0..1 Reference(Patient) The subject of the Products and Services --></patient>
 <

 <created value="[dateTime]"/><!-- 0..1 Creation date -->

 <insurer><!-- 0..1 Reference(Organization) Insurance issuing organization --></insurer>
 <</requestProvider>
 <</requestOrganization>
 <</request>
 <</outcome>
 <

 <requestProvider><!-- 0..1 Reference(Practitioner|PractitionerRole|Organization) Responsible practitioner --></requestProvider>
 <request><!-- 0..1 Reference(Claim) Id of resource triggering adjudication --></request>
 <outcome value="[code]"/><!-- 0..1 queued | complete | error | partial -->
 <disposition value="[string]"/><!-- 0..1 Disposition Message -->
 <preAuthRef value="[string]"/><!-- 0..1 Pre-Authorization/Determination Reference -->

 <payeeType><!-- 0..1 CodeableConcept Party to be paid any benefits payable --></payeeType>
 <
  <
  <

 <item>  <!-- 0..* Line items -->
  <itemSequence value="[positiveInt]"/><!-- 1..1 Service instance -->
  <noteNumber value="[positiveInt]"/><!-- 0..* List of note numbers which apply -->

  <adjudication>  <!-- 0..* Adjudication details -->
   <category><!-- 1..1 CodeableConcept Adjudication category such as co-pay, eligible, benefit, etc. --></category>
   <reason><!-- 0..1 CodeableConcept Explanation of Adjudication outcome --></reason>
   <amount><!-- 0..1 Money Monetary amount --></amount>
   <

   <value value="[decimal]"/><!-- 0..1 Non-monetary value -->

  </adjudication>
  <
   <
   <
   <</adjudication>
   <
    <
    <
    <</adjudication>

  <detail>  <!-- 0..* Detail line items -->
   <detailSequence value="[positiveInt]"/><!-- 1..1 Service instance -->
   <noteNumber value="[positiveInt]"/><!-- 0..* List of note numbers which apply -->
   <adjudication><!-- 0..* Content as for ClaimResponse.item.adjudication Detail level adjudication details --></adjudication>
   <subDetail>  <!-- 0..* Subdetail line items -->
    <subDetailSequence value="[positiveInt]"/><!-- 1..1 Service instance -->
    <noteNumber value="[positiveInt]"/><!-- 0..* List of note numbers which apply -->
    <adjudication><!-- 0..* Content as for ClaimResponse.item.adjudication Subdetail level adjudication details --></adjudication>

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

 <addItem>  <!-- 0..* Insurer added line items -->
  <itemSequence value="[positiveInt]"/><!-- 0..* Service instances -->
  <detailSequence value="[positiveInt]"/><!-- 0..* Detail sequence number -->
  <subdetailSequence value="[positiveInt]"/><!-- 0..* Subdetail sequence number -->
  <provider><!-- 0..* Reference(Practitioner|PractitionerRole|Organization) Authorized providers --></provider>
  <billcode><!-- 0..1 CodeableConcept Group, Service or Product --></billcode>
  <modifier><!-- 0..* CodeableConcept Service/Product billing modifiers --></modifier>
  <programCode><!-- 0..* CodeableConcept Program specific reason for item inclusion --></programCode>
  <serviced[x]><!-- 0..1 date|Period Date or dates of Service --></serviced[x]>
  <location[x]><!-- 0..1 CodeableConcept|Address|Reference(Location) Place of service --></location[x]>
  <quantity><!-- 0..1 Quantity(SimpleQuantity) Count of Products or Services --></quantity>
  <unitPrice><!-- 0..1 Money Fee, charge or cost per point --></unitPrice>
  <factor value="[decimal]"/><!-- 0..1 Price scaling factor -->
  <net><!-- 0..1 Money Total item cost --></net>
  <bodySite><!-- 0..1 CodeableConcept Service Location --></bodySite>
  <subSite><!-- 0..* CodeableConcept Service Sub-location --></subSite>
  <noteNumber value="[positiveInt]"/><!-- 0..* List of note numbers which apply -->
  <adjudication><!-- 0..* Content as for ClaimResponse.item.adjudication Added items adjudication --></adjudication>
  <detail>  <!-- 0..* Insurer added line items -->
   <billcode><!-- 0..1 CodeableConcept Group, Service or Product --></billcode>
   <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 point --></unitPrice>
   <factor value="[decimal]"/><!-- 0..1 Price scaling factor -->
   <net><!-- 0..1 Money Total item cost --></net>
   <noteNumber value="[positiveInt]"/><!-- 0..* List of note numbers which apply -->
   <adjudication><!-- 0..* Content as for ClaimResponse.item.adjudication Added items detail adjudication --></adjudication>
   <subDetail>  <!-- 0..* Insurer added line items -->
    <billcode><!-- 0..1 CodeableConcept Group, Service or Product --></billcode>
    <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 point --></unitPrice>
    <factor value="[decimal]"/><!-- 0..1 Price scaling factor -->
    <net><!-- 0..1 Money Total item cost --></net>
    <noteNumber value="[positiveInt]"/><!-- 0..* List of note numbers which apply -->
    <adjudication><!-- 0..* Content as for ClaimResponse.item.adjudication Added items detail adjudication --></adjudication>
   </subDetail>

  </detail>
 </addItem>
 <error>  <!-- 0..* Processing errors -->
  <
  <
  <
  <</code>

  <itemSequence value="[positiveInt]"/><!-- 0..1 Item sequence number -->
  <detailSequence value="[positiveInt]"/><!-- 0..1 Detail sequence number -->
  <subDetailSequence value="[positiveInt]"/><!-- 0..1 Subdetail sequence number -->
  <code><!-- 1..1 CodeableConcept Error code detailing processing issues --></code>

 </error>
 <</totalCost>
 <</unallocDeductable>
 <</totalBenefit>
 <

 <total>  <!-- 0..* Adjudication totals -->
  <category><!-- 1..1 CodeableConcept Adjudication category such as submitted, co-pay, eligible, benefit, etc. --></category>
  <amount><!-- 1..1 Money Monetary amount --></amount>
 </total>
 <payment>  <!-- 0..1 Payment Details -->

  <type><!-- 0..1 CodeableConcept Partial or Complete --></type>
  <adjustment><!-- 0..1 Money Payment adjustment for non-Claim issues --></adjustment>
  <adjustmentReason><!-- 0..1 CodeableConcept Explanation for the non-claim adjustment --></adjustmentReason>
  <

  <date value="[date]"/><!-- 0..1 Expected data of Payment -->

  <amount><!-- 0..1 Money Payable amount after adjustment --></amount>
  <identifier><!-- 0..1 Identifier Identifier of the payment instrument --></identifier>
 </payment>
 <reserved><!-- 0..1 Coding Funds reserved status --></reserved>
 <form><!-- 0..1 CodeableConcept Printed Form Identifier --></form>
 <processNote>  <!-- 0..* Processing notes -->
  <
  <</type>
  <

  <number value="[positiveInt]"/><!-- 0..1 Sequence Number for this note -->
  <type value="[code]"/><!-- 0..1 display | print | printoper -->
  <text value="[string]"/><!-- 0..1 Note explanatory text -->

  <language><!-- 0..1 CodeableConcept Language if different from the resource --></language>
 </processNote>
 <communicationRequest><!-- 0..* Reference(CommunicationRequest) Request for additional information --></communicationRequest>
 <insurance>  <!-- 0..* Insurance or medical plan -->
  <
  <

  <sequence value="[positiveInt]"/><!-- 1..1 Service instance identifier -->
  <focal value="[boolean]"/><!-- 1..1 Is the focal Coverage -->

  <coverage><!-- 1..1 Reference(Coverage) Insurance information --></coverage>
  <
  <

  <businessArrangement value="[string]"/><!-- 0..1 Business agreement -->

  <claimResponse><!-- 0..1 Reference(ClaimResponse) Adjudication results --></claimResponse>
 </insurance>
</ClaimResponse>

JSON Template 

{doco
  "resourceType" : "",

  "resourceType" : "ClaimResponse",

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

  "identifier" : [{ Identifier }], // Response  number
  "status" : "<code>", // active | cancelled | draft | entered-in-error
  "type" : { CodeableConcept }, // Type or discipline
  "subType" : { CodeableConcept }, // Finer grained claim type information
  "use" : "<code>", // claim | preauthorization | predetermination
  "patient" : { Reference(Patient) }, // The subject of the Products and Services
  "created" : "<dateTime>", // Creation date
  "insurer" : { Reference(Organization) }, // Insurance issuing organization
  "requestProvider" : { Reference(Practitioner|PractitionerRole|Organization) }, // Responsible practitioner
  "request" : { Reference(Claim) }, // Id of resource triggering adjudication
  "outcome" : "<code>", // queued | complete | error | partial
  "disposition" : "<string>", // Disposition Message
  "preAuthRef" : "<string>", // Pre-Authorization/Determination Reference
  "payeeType" : { CodeableConcept }, // Party to be paid any benefits payable
  "item" : [{ // Line items
    "itemSequence" : "<positiveInt>", // R!  Service instance
    "noteNumber" : ["<positiveInt>"], // List of note numbers which apply
    "adjudication" : [{ // Adjudication details
      "category" : { CodeableConcept }, // R!  Adjudication category such as co-pay, eligible, benefit, etc.
      "reason" : { CodeableConcept }, // Explanation of Adjudication outcome
      "amount" : { Money }, // Monetary amount
      "value" : <decimal> // Non-monetary value

    }],
    "
      "
      "
      "
      "
        "
        "
        "

    "detail" : [{ // Detail line items
      "detailSequence" : "<positiveInt>", // R!  Service instance
      "noteNumber" : ["<positiveInt>"], // List of note numbers which apply
      "adjudication" : [{ Content as for ClaimResponse.item.adjudication }], // Detail level adjudication details
      "subDetail" : [{ // Subdetail line items
        "subDetailSequence" : "<positiveInt>", // R!  Service instance
        "noteNumber" : ["<positiveInt>"], // List of note numbers which apply
        "adjudication" : [{ Content as for ClaimResponse.item.adjudication }] // Subdetail level adjudication details

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

  "addItem" : [{ // Insurer added line items
    "itemSequence" : ["<positiveInt>"], // Service instances
    "detailSequence" : ["<positiveInt>"], // Detail sequence number
    "subdetailSequence" : ["<positiveInt>"], // Subdetail sequence number
    "provider" : [{ Reference(Practitioner|PractitionerRole|Organization) }], // Authorized providers
    "billcode" : { CodeableConcept }, // Group, Service or Product
    "modifier" : [{ CodeableConcept }], // Service/Product billing modifiers
    "programCode" : [{ CodeableConcept }], // Program specific reason for item inclusion
    // serviced[x]: Date or dates of Service. One of these 2:

    "servicedDate" : "<date>",
    "servicedPeriod" : { Period },
    // location[x]: Place of service. 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 point
    "factor" : <decimal>, // Price scaling factor
    "net" : { Money }, // Total item cost
    "bodySite" : { CodeableConcept }, // Service Location
    "subSite" : [{ CodeableConcept }], // Service Sub-location
    "noteNumber" : ["<positiveInt>"], // List of note numbers which apply
    "adjudication" : [{ Content as for ClaimResponse.item.adjudication }], // Added items adjudication
    "detail" : [{ // Insurer added line items
      "billcode" : { CodeableConcept }, // Group, Service or Product
      "modifier" : [{ CodeableConcept }], // Service/Product billing modifiers
      "quantity" : { Quantity(SimpleQuantity) }, // Count of Products or Services
      "unitPrice" : { Money }, // Fee, charge or cost per point
      "factor" : <decimal>, // Price scaling factor
      "net" : { Money }, // Total item cost
      "noteNumber" : ["<positiveInt>"], // List of note numbers which apply
      "adjudication" : [{ Content as for ClaimResponse.item.adjudication }], // Added items detail adjudication
      "subDetail" : [{ // Insurer added line items
        "billcode" : { CodeableConcept }, // Group, Service or Product
        "modifier" : [{ CodeableConcept }], // Service/Product billing modifiers
        "quantity" : { Quantity(SimpleQuantity) }, // Count of Products or Services
        "unitPrice" : { Money }, // Fee, charge or cost per point
        "factor" : <decimal>, // Price scaling factor
        "net" : { Money }, // Total item cost
        "noteNumber" : ["<positiveInt>"], // List of note numbers which apply
        "adjudication" : [{ Content as for ClaimResponse.item.adjudication }] // Added items detail adjudication
      }]

    }]
  }],
  "
    "
    "
    "
    "

  "error" : [{ // Processing errors
    "itemSequence" : "<positiveInt>", // Item sequence number
    "detailSequence" : "<positiveInt>", // Detail sequence number
    "subDetailSequence" : "<positiveInt>", // Subdetail sequence number
    "code" : { CodeableConcept } // R!  Error code detailing processing issues

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

  "total" : [{ // Adjudication totals
    "category" : { CodeableConcept }, // R!  Adjudication category such as submitted, co-pay, eligible, benefit, etc.
    "amount" : { Money } // R!  Monetary amount
  }],
  "payment" : { // Payment Details
    "type" : { CodeableConcept }, // Partial or Complete
    "adjustment" : { Money }, // Payment adjustment for non-Claim issues
    "adjustmentReason" : { CodeableConcept }, // Explanation for the non-claim adjustment
    "date" : "<date>", // Expected data of Payment
    "amount" : { Money }, // Payable amount after adjustment
    "identifier" : { Identifier } // Identifier of the payment instrument

  },
  "
  "
  "
    "
    "
    "
    "

  "reserved" : { Coding }, // Funds reserved status
  "form" : { CodeableConcept }, // Printed Form Identifier
  "processNote" : [{ // Processing notes
    "number" : "<positiveInt>", // Sequence Number for this note
    "type" : "<code>", // display | print | printoper
    "text" : "<string>", // Note explanatory text
    "language" : { CodeableConcept } // Language if different from the resource

  }],
  "
  "
    "
    "
    "
    "
    "
    "

  "communicationRequest" : [{ Reference(CommunicationRequest) }], // Request for additional information
  "insurance" : [{ // Insurance or medical plan
    "sequence" : "<positiveInt>", // R!  Service instance identifier
    "focal" : <boolean>, // R!  Is the focal Coverage
    "coverage" : { Reference(Coverage) }, // R!  Insurance information
    "businessArrangement" : "<string>", // Business agreement
    "claimResponse" : { Reference(ClaimResponse) } // Adjudication results

  }]
}

Turtle Template 

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


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

  # from Resource: .id, .meta, .implicitRules, and .language
  # from DomainResource: .text, .contained, .extension, and .modifierExtension
  fhir:

  fhir:ClaimResponse.identifier [ Identifier ], ... ; # 0..* Response  number

  fhir:ClaimResponse.status [ code ]; # 0..1 active | cancelled | draft | entered-in-error
  fhir:ClaimResponse.type [ CodeableConcept ]; # 0..1 Type or discipline
  fhir:ClaimResponse.subType [ CodeableConcept ]; # 0..1 Finer grained claim type information
  fhir:ClaimResponse.use [ code ]; # 0..1 claim | preauthorization | predetermination

  fhir:ClaimResponse.patient [ Reference(Patient) ]; # 0..1 The subject of the Products and Services
  fhir:

  fhir:ClaimResponse.created [ dateTime ]; # 0..1 Creation date

  fhir:ClaimResponse.insurer [ Reference(Organization) ]; # 0..1 Insurance issuing organization
  fhir:
  fhir:
  fhir:
  fhir:

  fhir:ClaimResponse.requestProvider [ Reference(Practitioner|PractitionerRole|Organization) ]; # 0..1 Responsible practitioner
  fhir:ClaimResponse.request [ Reference(Claim) ]; # 0..1 Id of resource triggering adjudication
  fhir:ClaimResponse.outcome [ code ]; # 0..1 queued | complete | error | partial

  fhir:ClaimResponse.disposition [ string ]; # 0..1 Disposition Message
  fhir:ClaimResponse.preAuthRef [ string ]; # 0..1 Pre-Authorization/Determination Reference

  fhir:ClaimResponse.payeeType [ CodeableConcept ]; # 0..1 Party to be paid any benefits payable
  fhir:
    fhir:

  fhir:ClaimResponse.item [ # 0..* Line items
    fhir:ClaimResponse.item.itemSequence [ positiveInt ]; # 1..1 Service instance

    fhir:ClaimResponse.item.noteNumber [ positiveInt ], ... ; # 0..* List of note numbers which apply
    fhir:ClaimResponse.item.adjudication [ # 0..* Adjudication details
      fhir:ClaimResponse.item.adjudication.category [ CodeableConcept ]; # 1..1 Adjudication category such as co-pay, eligible, benefit, etc.
      fhir:ClaimResponse.item.adjudication.reason [ CodeableConcept ]; # 0..1 Explanation of Adjudication outcome
      fhir:ClaimResponse.item.adjudication.amount [ Money ]; # 0..1 Monetary amount
      fhir:ClaimResponse.item.adjudication.value [ decimal ]; # 0..1 Non-monetary value
    ], ...;
    fhir:
      fhir:

    fhir:ClaimResponse.item.detail [ # 0..* Detail line items
      fhir:ClaimResponse.item.detail.detailSequence [ positiveInt ]; # 1..1 Service instance

      fhir:ClaimResponse.item.detail.noteNumber [ positiveInt ], ... ; # 0..* List of note numbers which apply
      fhir:
      fhir:
        fhir:

      fhir:ClaimResponse.item.detail.adjudication [ See ClaimResponse.item.adjudication ], ... ; # 0..* Detail level adjudication details
      fhir:ClaimResponse.item.detail.subDetail [ # 0..* Subdetail line items
        fhir:ClaimResponse.item.detail.subDetail.subDetailSequence [ positiveInt ]; # 1..1 Service instance

        fhir:ClaimResponse.item.detail.subDetail.noteNumber [ positiveInt ], ... ; # 0..* List of note numbers which apply
        fhir:

        fhir:ClaimResponse.item.detail.subDetail.adjudication [ See ClaimResponse.item.adjudication ], ... ; # 0..* Subdetail level adjudication details

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

  fhir:ClaimResponse.addItem [ # 0..* Insurer added line items
    fhir:ClaimResponse.addItem.itemSequence [ positiveInt ], ... ; # 0..* Service instances
    fhir:ClaimResponse.addItem.detailSequence [ positiveInt ], ... ; # 0..* Detail sequence number
    fhir:ClaimResponse.addItem.subdetailSequence [ positiveInt ], ... ; # 0..* Subdetail sequence number
    fhir:ClaimResponse.addItem.provider [ Reference(Practitioner|PractitionerRole|Organization) ], ... ; # 0..* Authorized providers
    fhir:ClaimResponse.addItem.billcode [ CodeableConcept ]; # 0..1 Group, Service or Product
    fhir:ClaimResponse.addItem.modifier [ CodeableConcept ], ... ; # 0..* Service/Product billing modifiers
    fhir:ClaimResponse.addItem.programCode [ CodeableConcept ], ... ; # 0..* Program specific reason for item inclusion
    # ClaimResponse.addItem.serviced[x] : 0..1 Date or dates of Service. One of these 2
      fhir:ClaimResponse.addItem.servicedDate [ date ]
      fhir:ClaimResponse.addItem.servicedPeriod [ Period ]
    # ClaimResponse.addItem.location[x] : 0..1 Place of service. 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 point
    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 Service Location
    fhir:ClaimResponse.addItem.subSite [ CodeableConcept ], ... ; # 0..* Service Sub-location

    fhir:ClaimResponse.addItem.noteNumber [ positiveInt ], ... ; # 0..* List of note numbers which apply
    fhir:
    fhir:
      fhir:
      fhir:
      fhir:
      fhir:
      fhir:

    fhir:ClaimResponse.addItem.adjudication [ See ClaimResponse.item.adjudication ], ... ; # 0..* Added items adjudication
    fhir:ClaimResponse.addItem.detail [ # 0..* Insurer added line items
      fhir:ClaimResponse.addItem.detail.billcode [ CodeableConcept ]; # 0..1 Group, Service or Product
      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 point
      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..* List of note numbers which apply
      fhir:

      fhir:ClaimResponse.addItem.detail.adjudication [ See ClaimResponse.item.adjudication ], ... ; # 0..* Added items detail adjudication
      fhir:ClaimResponse.addItem.detail.subDetail [ # 0..* Insurer added line items
        fhir:ClaimResponse.addItem.detail.subDetail.billcode [ CodeableConcept ]; # 0..1 Group, Service or Product
        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 point
        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..* List of note numbers which apply
        fhir:ClaimResponse.addItem.detail.subDetail.adjudication [ See ClaimResponse.item.adjudication ], ... ; # 0..* Added items detail adjudication
      ], ...;

    ], ...;
  ], ...;
  fhir:ClaimResponse.error [ # 0..* Processing errors
    fhir:
    fhir:
    fhir:
    fhir:

    fhir:ClaimResponse.error.itemSequence [ positiveInt ]; # 0..1 Item sequence number
    fhir:ClaimResponse.error.detailSequence [ positiveInt ]; # 0..1 Detail sequence number
    fhir:ClaimResponse.error.subDetailSequence [ positiveInt ]; # 0..1 Subdetail sequence number
    fhir:ClaimResponse.error.code [ CodeableConcept ]; # 1..1 Error code detailing processing issues

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

  fhir:ClaimResponse.total [ # 0..* Adjudication totals
    fhir:ClaimResponse.total.category [ CodeableConcept ]; # 1..1 Adjudication category such as submitted, co-pay, eligible, benefit, etc.
    fhir:ClaimResponse.total.amount [ Money ]; # 1..1 Monetary amount
  ], ...;
  fhir:ClaimResponse.payment [ # 0..1 Payment Details

    fhir:ClaimResponse.payment.type [ CodeableConcept ]; # 0..1 Partial or Complete
    fhir:ClaimResponse.payment.adjustment [ Money ]; # 0..1 Payment adjustment for non-Claim issues
    fhir:ClaimResponse.payment.adjustmentReason [ CodeableConcept ]; # 0..1 Explanation for the non-claim adjustment
    fhir:ClaimResponse.payment.date [ date ]; # 0..1 Expected data of Payment
    fhir:ClaimResponse.payment.amount [ Money ]; # 0..1 Payable amount after adjustment
    fhir:ClaimResponse.payment.identifier [ Identifier ]; # 0..1 Identifier of the payment instrument
  ];
  fhir:ClaimResponse.reserved [ Coding ]; # 0..1 Funds reserved status
  fhir:ClaimResponse.form [ CodeableConcept ]; # 0..1 Printed Form Identifier
  fhir:ClaimResponse.processNote [ # 0..* Processing notes
    fhir:ClaimResponse.processNote.number [ positiveInt ]; # 0..1 Sequence Number for this note
    fhir:

    fhir:ClaimResponse.processNote.type [ code ]; # 0..1 display | print | printoper

    fhir:ClaimResponse.processNote.text [ string ]; # 0..1 Note explanatory text
    fhir:ClaimResponse.processNote.language [ CodeableConcept ]; # 0..1 Language if different from the resource
  ], ...;
  fhir:ClaimResponse.communicationRequest [ Reference(CommunicationRequest) ], ... ; # 0..* Request for additional information
  fhir:ClaimResponse.insurance [ # 0..* Insurance or medical plan
    fhir:ClaimResponse.insurance.sequence [ positiveInt ]; # 1..1 Service instance identifier
    fhir:ClaimResponse.insurance.focal [ boolean ]; # 1..1 Is the focal Coverage
    fhir:ClaimResponse.insurance.coverage [ Reference(Coverage) ]; # 1..1 Insurance information
    fhir:ClaimResponse.insurance.businessArrangement [ string ]; # 0..1 Business agreement
    fhir:

    fhir:ClaimResponse.insurance.claimResponse [ Reference(ClaimResponse) ]; # 0..1 Adjudication results
  ], ...;
]

Changes since DSTU2 R3

ClaimResponse.item.adjudication.amount Type changed from Quantity{http://hl7.org/fhir/StructureDefinition/Money} to Money ClaimResponse.item.detail.adjudication Remove BackboneElement ClaimResponse.item.detail.subDetail.adjudication Remove BackboneElement ClaimResponse.addItem.service Min Cardinality changed from 1 to 0 Type changed from Coding to CodeableConcept ClaimResponse.addItem.fee Type changed from Quantity{http://hl7.org/fhir/StructureDefinition/Money} to Money ClaimResponse.addItem.adjudication Remove BackboneElement ClaimResponse.addItem.detail.service Min Cardinality changed from 1 to 0 Type changed from Coding to CodeableConcept ClaimResponse.addItem.detail.fee Type changed from Quantity{http://hl7.org/fhir/StructureDefinition/Money} to Money ClaimResponse.addItem.detail.adjudication Remove BackboneElement ClaimResponse.error.code Type changed from Coding to CodeableConcept Remove Binding http://hl7.org/fhir/ValueSet/adjudication-error (required)
ClaimResponse
ClaimResponse.status ClaimResponse.type
  • Added Element
ClaimResponse.patient ClaimResponse.subType
  • Added Element
ClaimResponse.insurer ClaimResponse.use
  • Added Element
ClaimResponse.outcome ClaimResponse.requestProvider
  • Type changed from code Reference(Practitioner) to CodeableConcept Remove Binding http://hl7.org/fhir/ValueSet/remittance-outcome (required) Reference(Practitioner|PractitionerRole|Organization)
ClaimResponse.payeeType ClaimResponse.outcome
  • Type changed from Coding to CodeableConcept to code
  • Add Binding http://hl7.org/fhir/ValueSet/remittance-outcome (required)
ClaimResponse.item.adjudication.category ClaimResponse.preAuthRef
  • Added Element
ClaimResponse.item.adjudication.reason ClaimResponse.item.itemSequence
  • Added Element
ClaimResponse.item.detail.noteNumber ClaimResponse.item.detail.detailSequence
  • Added Element
ClaimResponse.item.detail.subDetail.noteNumber ClaimResponse.item.detail.subDetail.subDetailSequence
  • Added Element
ClaimResponse.addItem.revenue ClaimResponse.addItem.itemSequence
  • Added Element
ClaimResponse.addItem.category ClaimResponse.addItem.detailSequence
  • Added Element
ClaimResponse.addItem.modifier ClaimResponse.addItem.subdetailSequence
  • Added Element
ClaimResponse.addItem.noteNumber ClaimResponse.addItem.provider
  • Added Element
ClaimResponse.addItem.detail.revenue ClaimResponse.addItem.billcode
  • Added Element
ClaimResponse.addItem.detail.category ClaimResponse.addItem.programCode
  • Added Element
ClaimResponse.addItem.detail.modifier ClaimResponse.addItem.serviced[x]
  • Added Element
ClaimResponse.addItem.detail.noteNumber ClaimResponse.addItem.location[x]
  • Added Element
ClaimResponse.totalCost ClaimResponse.addItem.quantity
  • Type changed from Quantity{http://hl7.org/fhir/StructureDefinition/Money} to Money Added Element
ClaimResponse.unallocDeductable ClaimResponse.addItem.unitPrice
  • Type changed from Quantity{http://hl7.org/fhir/StructureDefinition/Money} to Money Added Element
ClaimResponse.totalBenefit ClaimResponse.addItem.factor
  • Type changed from Quantity{http://hl7.org/fhir/StructureDefinition/Money} to Money Added Element
ClaimResponse.payment ClaimResponse.addItem.net
  • Added Element
ClaimResponse.payment.type ClaimResponse.addItem.bodySite
  • Added Element
ClaimResponse.payment.adjustment ClaimResponse.addItem.subSite
  • Added Element
ClaimResponse.payment.adjustmentReason ClaimResponse.addItem.detail.billcode
  • Added Element
ClaimResponse.payment.date ClaimResponse.addItem.detail.quantity
  • Added Element
ClaimResponse.payment.amount ClaimResponse.addItem.detail.unitPrice
  • Added Element
ClaimResponse.payment.identifier ClaimResponse.addItem.detail.factor
  • Added Element
ClaimResponse.form ClaimResponse.addItem.detail.net
  • Type changed from Coding to CodeableConcept Remove Binding http://hl7.org/fhir/ValueSet/forms (required) Added Element
ClaimResponse.processNote ClaimResponse.addItem.detail.subDetail
  • Added Element
ClaimResponse.processNote.number ClaimResponse.addItem.detail.subDetail.billcode
  • Added Element
ClaimResponse.processNote.type ClaimResponse.addItem.detail.subDetail.modifier
  • Added Element
ClaimResponse.processNote.text ClaimResponse.addItem.detail.subDetail.quantity
  • Added Element
ClaimResponse.processNote.language ClaimResponse.addItem.detail.subDetail.unitPrice
  • Added Element
ClaimResponse.communicationRequest ClaimResponse.addItem.detail.subDetail.factor
  • Added Element
ClaimResponse.insurance ClaimResponse.addItem.detail.subDetail.net
  • Added Element
ClaimResponse.insurance.sequence ClaimResponse.addItem.detail.subDetail.noteNumber
  • Added Element
ClaimResponse.insurance.focal ClaimResponse.addItem.detail.subDetail.adjudication
  • Added Element
ClaimResponse.insurance.coverage ClaimResponse.error.itemSequence
  • Added Element
ClaimResponse.insurance.businessArrangement ClaimResponse.error.detailSequence
  • Added Element
ClaimResponse.insurance.preAuthRef ClaimResponse.error.subDetailSequence
  • Added Element
ClaimResponse.insurance.claimResponse ClaimResponse.total
  • Added Element
ClaimResponse.ruleset ClaimResponse.total.category
  • deleted Added Element
ClaimResponse.originalRuleset ClaimResponse.total.amount
  • deleted Added Element
ClaimResponse.organization ClaimResponse.processNote.type
  • deleted Type changed from CodeableConcept to code
ClaimResponse.item.adjudication.code ClaimResponse.processNote.language
  • deleted Remove Binding http://hl7.org/fhir/ValueSet/languages (extensible)
ClaimResponse.item.detail.adjudication.code ClaimResponse.requestOrganization
  • deleted
ClaimResponse.item.detail.adjudication.amount ClaimResponse.item.sequenceLinkId
  • deleted
ClaimResponse.item.detail.adjudication.value ClaimResponse.item.detail.sequenceLinkId
  • deleted
ClaimResponse.item.detail.subDetail.adjudication.code ClaimResponse.item.detail.subDetail.sequenceLinkId
  • deleted
ClaimResponse.item.detail.subDetail.adjudication.amount ClaimResponse.addItem.sequenceLinkId
  • deleted
ClaimResponse.item.detail.subDetail.adjudication.value ClaimResponse.addItem.revenue
  • deleted
ClaimResponse.addItem.noteNumberLinkId ClaimResponse.addItem.category
  • deleted
ClaimResponse.addItem.adjudication.code ClaimResponse.addItem.service
  • deleted
ClaimResponse.addItem.adjudication.amount ClaimResponse.addItem.fee
  • deleted
ClaimResponse.addItem.adjudication.value ClaimResponse.addItem.detail.revenue
  • deleted
ClaimResponse.addItem.detail.adjudication.code ClaimResponse.addItem.detail.category
  • deleted
ClaimResponse.addItem.detail.adjudication.amount ClaimResponse.addItem.detail.service
  • deleted
ClaimResponse.addItem.detail.adjudication.value ClaimResponse.addItem.detail.fee
  • deleted
ClaimResponse.paymentAdjustment ClaimResponse.error.sequenceLinkId
  • deleted
ClaimResponse.paymentAdjustmentReason ClaimResponse.error.detailSequenceLinkId
  • deleted
ClaimResponse.paymentDate ClaimResponse.error.subdetailSequenceLinkId
  • deleted
ClaimResponse.paymentAmount ClaimResponse.totalCost
  • deleted
ClaimResponse.paymentRef ClaimResponse.unallocDeductable
  • deleted
ClaimResponse.note ClaimResponse.totalBenefit
  • deleted
ClaimResponse.coverage ClaimResponse.insurance.preAuthRef
  • deleted

See the Full Difference for further information

This analysis is available as XML or JSON .

See R3 <--> R4 Conversion Maps (status = 1 test of which 1 fail to execute .)

Structure

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

doco Documentation for this format

UML Diagram ( Legend )

ClaimResponse ( DomainResource ) The Response response business identifier identifier : Identifier [0..*] The status of the resource instance (this element modifies the meaning of other elements) status : code [0..1] « A code specifying the state of the resource instance. (Strength=Required) Financial Resource Status FinancialResourceStatusCodes ! » The category of claim, e.g, oral, pharmacy, vision, institutional, professional type : CodeableConcept [0..1] « The type or discipline-style of the claim. (Strength=Extensible) ClaimTypeCodes + » A finer grained suite of claim subtype codes which may convey Inpatient vs Outpatient and/or a specialty service. In the US the CMS Bill Type subType : CodeableConcept [0..1] « A more granulat claim typecode. (Strength=Example) ExampleClaimSubTypeCodes ?? » A claim, a list of completed goods and services; a preauthorization, a list or proposed goods and services; or a predetermination, a set of goods and services being considered, for which insurer adjudication is sought use : code [0..1] « Claim, preauthorization, predetermination. (Strength=Required) Use ! » Patient Resource patient : Reference [0..1] « Patient » The date when the enclosed suite of services were performed or completed this resource was created created : dateTime [0..1] The Insurer who produced this adjudicated response insurer : Reference [0..1] « Organization » The practitioner who is responsible for the services rendered to the patient requestProvider : Reference [0..1] « Practitioner | PractitionerRole | The organization which is responsible for the services rendered to the patient requestOrganization : Reference [0..1] Organization » Original request resource referrence reference request : Reference [0..1] « Claim » Processing outcome errror, Transaction: error, complete, partial or complete processing outcome : CodeableConcept code [0..1] « The result of the claim processing (Strength=Example) processing. (Strength=Required) Claim Processing ?? ClaimProcessingCodes ! » A description of the status of the adjudication disposition : string [0..1] A list of references from the Insurer to which these services pertain preAuthRef : string [0..1] Party to be reimbursed: Subscriber, provider, other payeeType : CodeableConcept [0..1] « A code for the party to be reimbursed. (Strength=Example) Claim Payee Type ?? » The total cost of the services reported totalCost : Money [0..1] The amount of deductible applied which was not allocated to any particular service line unallocDeductable : Money [0..1] Total amount of benefit payable (Equal to sum of the Benefit amounts from all detail lines and additions less the Unallocated Deductible) totalBenefit : Money [0..1] Status of funds reservation (For provider, for Patient, None) reserved : Coding [0..1] « For whom funds are to be reserved: (Patient, Provider, None). (Strength=Example) Funds Reservation ?? » The form to be used for printing the content form : CodeableConcept [0..1] « The forms codes. (Strength=Example) Form ?? » Request for additional supporting or authorizing information, such as: documents, images or resources communicationRequest : Reference [0..*] « CommunicationRequest » Item A service line number sequenceLinkId itemSequence : positiveInt [1..1] A list of note references to the notes provided below noteNumber : positiveInt [0..*] Adjudication Code indicating: Co-Pay, deductible, eligible, benefit, tax, etc category : CodeableConcept [1..1] « The adjudication codes. (Strength=Example) Adjudication Value AdjudicationValueCodes ?? » Adjudication reason such as limit reached reason : CodeableConcept [0..1] « The adjudication reason codes. (Strength=Example) Adjudication Reason AdjudicationReasonCodes ?? » Monetary amount associated with the code amount : Money [0..1] A non-monetary value for example a percentage. Mutually exclusive to the amount element above value : decimal [0..1] ItemDetail A service line number sequenceLinkId detailSequence : positiveInt [1..1] A list of note references to the notes provided below noteNumber : positiveInt [0..*] SubDetail A service line number sequenceLinkId subDetailSequence : positiveInt [1..1] A list of note references to the notes provided below noteNumber : positiveInt [0..*] AddedItem List of input service items which this service line is intended to replace sequenceLinkId itemSequence : positiveInt [0..*] The type sequence number of reveneu or cost center providing the product and/or service addition within the line item submitted which contains the error. This value is omitted when the error is not related to an Addition revenue detailSequence : CodeableConcept positiveInt [0..1] [0..*] Codes for The sequence number of the revenue or cost centers supplying addition within the service and/or products. (Strength=Example) line item submitted which contains the error. This value is omitted when the error is not related to an Addition Example Revenue Center subdetailSequence ?? : positiveInt [0..*] Health Care Service Type Codes The providers who are authorized for the services rendered to identify the classification of service or benefits patient category provider : CodeableConcept Reference [0..1] [0..*] « Practitioner | PractitionerRole | Benefit subcategories such as: oral-basic, major, glasses (Strength=Example) Benefit SubCategory Organization ?? » A code to indicate the Professional Service or Product supplied service billcode : CodeableConcept [0..1] « Allowable service and product codes. (Strength=Example) USCLS USCLSCodes ?? » Item typification or modifiers codes, eg e.g. 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 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 ?? » For programs which require reason codes for the inclusion or covering of this billed item under the program or sub-program programCode : CodeableConcept [0..*] « Program specific reason codes. (Strength=Example) ExampleProgramReasonCodes ?? » The date or dates when the service or product was supplied, performed or completed serviced[x] : Type [0..1] « date | Period » Where the service was provided location[x] : Type [0..1] « CodeableConcept | Address | Reference ( Location ); Place of service: pharmacy,school, prison, etc. (Strength=Example) ExampleServicePlaceCodes ?? » The number of repetitions of a service or product quantity : Quantity ( SimpleQuantity ) [0..1] If the item is a node then this is the fee charged for the professional product or service, otherwise this is the total of the fees for the children 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. product or charge. For example, the formula: unit Quantity * unit Price (Cost per Point) * factor Number * points = net Amount. Quantity, factor and points are assumed to be 1 if not supplied fee 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 site, e.g. limb region or tooth surface(s) subSite : CodeableConcept [0..*] « The code for the tooth surface and surface combinations. (Strength=Example) SurfaceCodes ?? » A list of note references to the notes provided below noteNumber : positiveInt [0..*] AddedItemsDetail AddedItemDetail The type of reveneu or cost center providing A code to indicate the product and/or service Professional Service or Product supplied revenue billcode : CodeableConcept [0..1] « Allowable service and product codes. (Strength=Example) USCLSCodes ?? » Codes Item typification or modifiers codes, e.g. for Oral whether the revenue treatment is cosmetic or cost centers supplying associated with TMJ, or for medical whether the service and/or products. treatment was outside the clinic or out of office hours 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) Example Revenue Center ModifierTypeCodes ?? » Health Care Service Type Codes to identify The number of repetitions of a service or product quantity : Quantity ( SimpleQuantity ) [0..1] If the classification item is a node then this is the fee for the product or service, otherwise this is the total of the fees for the children 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 benefits product or charge. For example, the formula: unit Quantity * unit Price (Cost per Point) * factor Number * points = net Amount. Quantity, factor and points are assumed to be 1 if not supplied category net : CodeableConcept Money [0..1] Benefit subcategories such as: oral-basic, major, glasses (Strength=Example) A list of note references to the notes provided below Benefit SubCategory noteNumber ?? : positiveInt [0..*] AddedItemSubDetail A code to indicate the Professional Service or Product supplied service billcode : CodeableConcept [0..1] « Allowable service and product codes. (Strength=Example) USCLS USCLSCodes ?? » Item typification or modifiers codes, eg e.g. 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 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 a node then this is the fee charged for the professional product or service, otherwise this is the total of the fees for the children 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. product or charge. For example, the formula: unit Quantity * unit Price (Cost per Point) * factor Number * points = net Amount. Quantity, factor and points are assumed to be 1 if not supplied fee net : Money [0..1] A list of note references to the notes provided below noteNumber : positiveInt [0..*] Error The sequence number of the line item submitted which contains the error. This value is omitted when the error is elsewhere sequenceLinkId itemSequence : positiveInt [0..1] The sequence number of the addition within the line item submitted which contains the error. This value is omitted when the error is not related to an Addition detailSequenceLinkId detailSequence : positiveInt [0..1] The sequence number of the addition within the line item submitted which contains the error. This value is omitted when the error is not related to an Addition subdetailSequenceLinkId subDetailSequence : positiveInt [0..1] An error code,from code, from a specified code system, which details why the claim could not be adjudicated code : CodeableConcept [1..1] « The adjudication error codes. (Strength=Example) Adjudication Error ?? » Total Code indicating: Submitted, Co-Pay, deductible, eligible, benefit, tax, etc category : CodeableConcept [1..1] « The adjudication codes. (Strength=Example) AdjudicationValueCodes ?? » Monitory amount associated with the code amount : Money [1..1] Payment Whether this represents partial or complete payment of the claim type : CodeableConcept [0..1] « The type (partial, complete) of the payment payment. (Strength=Example) Example Payment Type ExamplePaymentTypeCodes ?? » Adjustment to the payment of this transaction which is not related to adjudication of this transaction adjustment : Money [0..1] Reason for the payment adjustment adjustmentReason : CodeableConcept [0..1] « Payment Adjustment reason codes. (Strength=Example) Payment Adjustment Reason PaymentAdjustmentReasonCodes ?? » Estimated payment data date : date [0..1] Payable less any payment adjustment amount : Money [0..1] Payment identifier identifier : Identifier [0..1] Note An integer associated with each note which may be referred to from each service line item number : positiveInt [0..1] The note purpose: Print/Display type : CodeableConcept code [0..1] « The presentation types of notes. (Strength=Required) NoteType ! » The note text text : string [0..1] The ISO-639-1 alpha 2 code in lower case for the language, optionally followed by a hyphen and the ISO-3166-1 alpha 2 code for the region in upper case; e.g. "en" "en" for English, or "en-US" "en-US" for American English versus "en-EN" "en-EN" for England English language : CodeableConcept [0..1] « A human language. (Strength=Extensible) (Strength=Preferred) Common Languages + ? » Insurance A service line item sequence : positiveInt [1..1] The instance number of the Coverage which is the focus for adjudication. The Coverage against which the claim is to be adjudicated focal : boolean [1..1] Reference to the program or plan identification, underwriter or payor coverage : Reference [1..1] « Coverage » The contract number of a business agreement which describes the terms and conditions businessArrangement : string [0..1] A list of references from the Insurer to which these services pertain preAuthRef : string [0..*] The Coverages adjudication details claimResponse : Reference [0..1] « ClaimResponse » The adjudication results adjudication [0..*] The adjudications adjudication results adjudication [0..*] The adjudications adjudication results adjudication [0..*] The third tier third-tier service adjudications for submitted services subDetail [0..*] The second tier second-tier service adjudications for submitted services detail [0..*] The first tier first-tier service adjudications for submitted services item [0..*] The adjudications adjudication results adjudication [0..*] The adjudications adjudication results adjudication [0..*] The second tier adjudication results adjudication [0..*] The third-tier service adjudications for payor added services subDetail [0..*] The second-tier service adjudications for payor added services detail [0..*] The first tier first-tier service adjudications for payor added services addItem [0..*] Mutually exclusive with Services Provided (Item) error [0..*] Totals for amounts submitted, co-pays, benefits payable etc total [0..*] Payment details for the claim if the claim has been paid payment [0..1] Note text processNote [0..*] Financial instrument by which payment information for health care insurance [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>
 <

 <identifier><!-- 0..* Identifier Response  number --></identifier>
 <status value="[code]"/><!-- 0..1 active | cancelled | draft | entered-in-error -->
 <type><!-- 0..1 CodeableConcept Type or discipline --></type>
 <subType><!-- 0..1 CodeableConcept Finer grained claim type information --></subType>
 <use value="[code]"/><!-- 0..1 claim | preauthorization | predetermination -->

 <patient><!-- 0..1 Reference(Patient) The subject of the Products and Services --></patient>
 <

 <created value="[dateTime]"/><!-- 0..1 Creation date -->

 <insurer><!-- 0..1 Reference(Organization) Insurance issuing organization --></insurer>
 <</requestProvider>
 <</requestOrganization>
 <</request>
 <</outcome>
 <

 <requestProvider><!-- 0..1 Reference(Practitioner|PractitionerRole|Organization) Responsible practitioner --></requestProvider>
 <request><!-- 0..1 Reference(Claim) Id of resource triggering adjudication --></request>
 <outcome value="[code]"/><!-- 0..1 queued | complete | error | partial -->
 <disposition value="[string]"/><!-- 0..1 Disposition Message -->
 <preAuthRef value="[string]"/><!-- 0..1 Pre-Authorization/Determination Reference -->

 <payeeType><!-- 0..1 CodeableConcept Party to be paid any benefits payable --></payeeType>
 <
  <
  <

 <item>  <!-- 0..* Line items -->
  <itemSequence value="[positiveInt]"/><!-- 1..1 Service instance -->
  <noteNumber value="[positiveInt]"/><!-- 0..* List of note numbers which apply -->

  <adjudication>  <!-- 0..* Adjudication details -->
   <category><!-- 1..1 CodeableConcept Adjudication category such as co-pay, eligible, benefit, etc. --></category>
   <reason><!-- 0..1 CodeableConcept Explanation of Adjudication outcome --></reason>
   <amount><!-- 0..1 Money Monetary amount --></amount>
   <

   <value value="[decimal]"/><!-- 0..1 Non-monetary value -->

  </adjudication>
  <
   <
   <
   <</adjudication>
   <
    <
    <
    <</adjudication>

  <detail>  <!-- 0..* Detail line items -->
   <detailSequence value="[positiveInt]"/><!-- 1..1 Service instance -->
   <noteNumber value="[positiveInt]"/><!-- 0..* List of note numbers which apply -->
   <adjudication><!-- 0..* Content as for ClaimResponse.item.adjudication Detail level adjudication details --></adjudication>
   <subDetail>  <!-- 0..* Subdetail line items -->
    <subDetailSequence value="[positiveInt]"/><!-- 1..1 Service instance -->
    <noteNumber value="[positiveInt]"/><!-- 0..* List of note numbers which apply -->
    <adjudication><!-- 0..* Content as for ClaimResponse.item.adjudication Subdetail level adjudication details --></adjudication>

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

 <addItem>  <!-- 0..* Insurer added line items -->
  <itemSequence value="[positiveInt]"/><!-- 0..* Service instances -->
  <detailSequence value="[positiveInt]"/><!-- 0..* Detail sequence number -->
  <subdetailSequence value="[positiveInt]"/><!-- 0..* Subdetail sequence number -->
  <provider><!-- 0..* Reference(Practitioner|PractitionerRole|Organization) Authorized providers --></provider>
  <billcode><!-- 0..1 CodeableConcept Group, Service or Product --></billcode>
  <modifier><!-- 0..* CodeableConcept Service/Product billing modifiers --></modifier>
  <programCode><!-- 0..* CodeableConcept Program specific reason for item inclusion --></programCode>
  <serviced[x]><!-- 0..1 date|Period Date or dates of Service --></serviced[x]>
  <location[x]><!-- 0..1 CodeableConcept|Address|Reference(Location) Place of service --></location[x]>
  <quantity><!-- 0..1 Quantity(SimpleQuantity) Count of Products or Services --></quantity>
  <unitPrice><!-- 0..1 Money Fee, charge or cost per point --></unitPrice>
  <factor value="[decimal]"/><!-- 0..1 Price scaling factor -->
  <net><!-- 0..1 Money Total item cost --></net>
  <bodySite><!-- 0..1 CodeableConcept Service Location --></bodySite>
  <subSite><!-- 0..* CodeableConcept Service Sub-location --></subSite>
  <noteNumber value="[positiveInt]"/><!-- 0..* List of note numbers which apply -->
  <adjudication><!-- 0..* Content as for ClaimResponse.item.adjudication Added items adjudication --></adjudication>
  <detail>  <!-- 0..* Insurer added line items -->
   <billcode><!-- 0..1 CodeableConcept Group, Service or Product --></billcode>
   <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 point --></unitPrice>
   <factor value="[decimal]"/><!-- 0..1 Price scaling factor -->
   <net><!-- 0..1 Money Total item cost --></net>
   <noteNumber value="[positiveInt]"/><!-- 0..* List of note numbers which apply -->
   <adjudication><!-- 0..* Content as for ClaimResponse.item.adjudication Added items detail adjudication --></adjudication>
   <subDetail>  <!-- 0..* Insurer added line items -->
    <billcode><!-- 0..1 CodeableConcept Group, Service or Product --></billcode>
    <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 point --></unitPrice>
    <factor value="[decimal]"/><!-- 0..1 Price scaling factor -->
    <net><!-- 0..1 Money Total item cost --></net>
    <noteNumber value="[positiveInt]"/><!-- 0..* List of note numbers which apply -->
    <adjudication><!-- 0..* Content as for ClaimResponse.item.adjudication Added items detail adjudication --></adjudication>
   </subDetail>

  </detail>
 </addItem>
 <error>  <!-- 0..* Processing errors -->
  <
  <
  <
  <</code>

  <itemSequence value="[positiveInt]"/><!-- 0..1 Item sequence number -->
  <detailSequence value="[positiveInt]"/><!-- 0..1 Detail sequence number -->
  <subDetailSequence value="[positiveInt]"/><!-- 0..1 Subdetail sequence number -->
  <code><!-- 1..1 CodeableConcept Error code detailing processing issues --></code>

 </error>
 <</totalCost>
 <</unallocDeductable>
 <</totalBenefit>
 <

 <total>  <!-- 0..* Adjudication totals -->
  <category><!-- 1..1 CodeableConcept Adjudication category such as submitted, co-pay, eligible, benefit, etc. --></category>
  <amount><!-- 1..1 Money Monetary amount --></amount>
 </total>
 <payment>  <!-- 0..1 Payment Details -->

  <type><!-- 0..1 CodeableConcept Partial or Complete --></type>
  <adjustment><!-- 0..1 Money Payment adjustment for non-Claim issues --></adjustment>
  <adjustmentReason><!-- 0..1 CodeableConcept Explanation for the non-claim adjustment --></adjustmentReason>
  <

  <date value="[date]"/><!-- 0..1 Expected data of Payment -->

  <amount><!-- 0..1 Money Payable amount after adjustment --></amount>
  <identifier><!-- 0..1 Identifier Identifier of the payment instrument --></identifier>
 </payment>
 <reserved><!-- 0..1 Coding Funds reserved status --></reserved>
 <form><!-- 0..1 CodeableConcept Printed Form Identifier --></form>
 <processNote>  <!-- 0..* Processing notes -->
  <
  <</type>
  <

  <number value="[positiveInt]"/><!-- 0..1 Sequence Number for this note -->
  <type value="[code]"/><!-- 0..1 display | print | printoper -->
  <text value="[string]"/><!-- 0..1 Note explanatory text -->

  <language><!-- 0..1 CodeableConcept Language if different from the resource --></language>
 </processNote>
 <communicationRequest><!-- 0..* Reference(CommunicationRequest) Request for additional information --></communicationRequest>
 <insurance>  <!-- 0..* Insurance or medical plan -->
  <
  <

  <sequence value="[positiveInt]"/><!-- 1..1 Service instance identifier -->
  <focal value="[boolean]"/><!-- 1..1 Is the focal Coverage -->

  <coverage><!-- 1..1 Reference(Coverage) Insurance information --></coverage>
  <
  <

  <businessArrangement value="[string]"/><!-- 0..1 Business agreement -->

  <claimResponse><!-- 0..1 Reference(ClaimResponse) Adjudication results --></claimResponse>
 </insurance>
</ClaimResponse>

JSON Template 

{doco
  "resourceType" : "",

  "resourceType" : "ClaimResponse",

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

  "identifier" : [{ Identifier }], // Response  number
  "status" : "<code>", // active | cancelled | draft | entered-in-error
  "type" : { CodeableConcept }, // Type or discipline
  "subType" : { CodeableConcept }, // Finer grained claim type information
  "use" : "<code>", // claim | preauthorization | predetermination
  "patient" : { Reference(Patient) }, // The subject of the Products and Services
  "created" : "<dateTime>", // Creation date
  "insurer" : { Reference(Organization) }, // Insurance issuing organization
  "requestProvider" : { Reference(Practitioner|PractitionerRole|Organization) }, // Responsible practitioner
  "request" : { Reference(Claim) }, // Id of resource triggering adjudication
  "outcome" : "<code>", // queued | complete | error | partial
  "disposition" : "<string>", // Disposition Message
  "preAuthRef" : "<string>", // Pre-Authorization/Determination Reference
  "payeeType" : { CodeableConcept }, // Party to be paid any benefits payable
  "item" : [{ // Line items
    "itemSequence" : "<positiveInt>", // R!  Service instance
    "noteNumber" : ["<positiveInt>"], // List of note numbers which apply
    "adjudication" : [{ // Adjudication details
      "category" : { CodeableConcept }, // R!  Adjudication category such as co-pay, eligible, benefit, etc.
      "reason" : { CodeableConcept }, // Explanation of Adjudication outcome
      "amount" : { Money }, // Monetary amount
      "value" : <decimal> // Non-monetary value

    }],
    "
      "
      "
      "
      "
        "
        "
        "

    "detail" : [{ // Detail line items
      "detailSequence" : "<positiveInt>", // R!  Service instance
      "noteNumber" : ["<positiveInt>"], // List of note numbers which apply
      "adjudication" : [{ Content as for ClaimResponse.item.adjudication }], // Detail level adjudication details
      "subDetail" : [{ // Subdetail line items
        "subDetailSequence" : "<positiveInt>", // R!  Service instance
        "noteNumber" : ["<positiveInt>"], // List of note numbers which apply
        "adjudication" : [{ Content as for ClaimResponse.item.adjudication }] // Subdetail level adjudication details

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

  "addItem" : [{ // Insurer added line items
    "itemSequence" : ["<positiveInt>"], // Service instances
    "detailSequence" : ["<positiveInt>"], // Detail sequence number
    "subdetailSequence" : ["<positiveInt>"], // Subdetail sequence number
    "provider" : [{ Reference(Practitioner|PractitionerRole|Organization) }], // Authorized providers
    "billcode" : { CodeableConcept }, // Group, Service or Product
    "modifier" : [{ CodeableConcept }], // Service/Product billing modifiers
    "programCode" : [{ CodeableConcept }], // Program specific reason for item inclusion
    // serviced[x]: Date or dates of Service. One of these 2:

    "servicedDate" : "<date>",
    "servicedPeriod" : { Period },
    // location[x]: Place of service. 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 point
    "factor" : <decimal>, // Price scaling factor
    "net" : { Money }, // Total item cost
    "bodySite" : { CodeableConcept }, // Service Location
    "subSite" : [{ CodeableConcept }], // Service Sub-location
    "noteNumber" : ["<positiveInt>"], // List of note numbers which apply
    "adjudication" : [{ Content as for ClaimResponse.item.adjudication }], // Added items adjudication
    "detail" : [{ // Insurer added line items
      "billcode" : { CodeableConcept }, // Group, Service or Product
      "modifier" : [{ CodeableConcept }], // Service/Product billing modifiers
      "quantity" : { Quantity(SimpleQuantity) }, // Count of Products or Services
      "unitPrice" : { Money }, // Fee, charge or cost per point
      "factor" : <decimal>, // Price scaling factor
      "net" : { Money }, // Total item cost
      "noteNumber" : ["<positiveInt>"], // List of note numbers which apply
      "adjudication" : [{ Content as for ClaimResponse.item.adjudication }], // Added items detail adjudication
      "subDetail" : [{ // Insurer added line items
        "billcode" : { CodeableConcept }, // Group, Service or Product
        "modifier" : [{ CodeableConcept }], // Service/Product billing modifiers
        "quantity" : { Quantity(SimpleQuantity) }, // Count of Products or Services
        "unitPrice" : { Money }, // Fee, charge or cost per point
        "factor" : <decimal>, // Price scaling factor
        "net" : { Money }, // Total item cost
        "noteNumber" : ["<positiveInt>"], // List of note numbers which apply
        "adjudication" : [{ Content as for ClaimResponse.item.adjudication }] // Added items detail adjudication
      }]

    }]
  }],
  "
    "
    "
    "
    "

  "error" : [{ // Processing errors
    "itemSequence" : "<positiveInt>", // Item sequence number
    "detailSequence" : "<positiveInt>", // Detail sequence number
    "subDetailSequence" : "<positiveInt>", // Subdetail sequence number
    "code" : { CodeableConcept } // R!  Error code detailing processing issues

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

  "total" : [{ // Adjudication totals
    "category" : { CodeableConcept }, // R!  Adjudication category such as submitted, co-pay, eligible, benefit, etc.
    "amount" : { Money } // R!  Monetary amount
  }],
  "payment" : { // Payment Details
    "type" : { CodeableConcept }, // Partial or Complete
    "adjustment" : { Money }, // Payment adjustment for non-Claim issues
    "adjustmentReason" : { CodeableConcept }, // Explanation for the non-claim adjustment
    "date" : "<date>", // Expected data of Payment
    "amount" : { Money }, // Payable amount after adjustment
    "identifier" : { Identifier } // Identifier of the payment instrument

  },
  "
  "
  "
    "
    "
    "
    "

  "reserved" : { Coding }, // Funds reserved status
  "form" : { CodeableConcept }, // Printed Form Identifier
  "processNote" : [{ // Processing notes
    "number" : "<positiveInt>", // Sequence Number for this note
    "type" : "<code>", // display | print | printoper
    "text" : "<string>", // Note explanatory text
    "language" : { CodeableConcept } // Language if different from the resource

  }],
  "
  "
    "
    "
    "
    "
    "
    "

  "communicationRequest" : [{ Reference(CommunicationRequest) }], // Request for additional information
  "insurance" : [{ // Insurance or medical plan
    "sequence" : "<positiveInt>", // R!  Service instance identifier
    "focal" : <boolean>, // R!  Is the focal Coverage
    "coverage" : { Reference(Coverage) }, // R!  Insurance information
    "businessArrangement" : "<string>", // Business agreement
    "claimResponse" : { Reference(ClaimResponse) } // Adjudication results

  }]
}

Turtle Template 

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


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

  # from Resource: .id, .meta, .implicitRules, and .language
  # from DomainResource: .text, .contained, .extension, and .modifierExtension
  fhir:

  fhir:ClaimResponse.identifier [ Identifier ], ... ; # 0..* Response  number

  fhir:ClaimResponse.status [ code ]; # 0..1 active | cancelled | draft | entered-in-error
  fhir:ClaimResponse.type [ CodeableConcept ]; # 0..1 Type or discipline
  fhir:ClaimResponse.subType [ CodeableConcept ]; # 0..1 Finer grained claim type information
  fhir:ClaimResponse.use [ code ]; # 0..1 claim | preauthorization | predetermination

  fhir:ClaimResponse.patient [ Reference(Patient) ]; # 0..1 The subject of the Products and Services
  fhir:

  fhir:ClaimResponse.created [ dateTime ]; # 0..1 Creation date

  fhir:ClaimResponse.insurer [ Reference(Organization) ]; # 0..1 Insurance issuing organization
  fhir:
  fhir:
  fhir:
  fhir:

  fhir:ClaimResponse.requestProvider [ Reference(Practitioner|PractitionerRole|Organization) ]; # 0..1 Responsible practitioner
  fhir:ClaimResponse.request [ Reference(Claim) ]; # 0..1 Id of resource triggering adjudication
  fhir:ClaimResponse.outcome [ code ]; # 0..1 queued | complete | error | partial

  fhir:ClaimResponse.disposition [ string ]; # 0..1 Disposition Message
  fhir:ClaimResponse.preAuthRef [ string ]; # 0..1 Pre-Authorization/Determination Reference

  fhir:ClaimResponse.payeeType [ CodeableConcept ]; # 0..1 Party to be paid any benefits payable
  fhir:
    fhir:

  fhir:ClaimResponse.item [ # 0..* Line items
    fhir:ClaimResponse.item.itemSequence [ positiveInt ]; # 1..1 Service instance

    fhir:ClaimResponse.item.noteNumber [ positiveInt ], ... ; # 0..* List of note numbers which apply
    fhir:ClaimResponse.item.adjudication [ # 0..* Adjudication details
      fhir:ClaimResponse.item.adjudication.category [ CodeableConcept ]; # 1..1 Adjudication category such as co-pay, eligible, benefit, etc.
      fhir:ClaimResponse.item.adjudication.reason [ CodeableConcept ]; # 0..1 Explanation of Adjudication outcome
      fhir:ClaimResponse.item.adjudication.amount [ Money ]; # 0..1 Monetary amount
      fhir:ClaimResponse.item.adjudication.value [ decimal ]; # 0..1 Non-monetary value
    ], ...;
    fhir:
      fhir:

    fhir:ClaimResponse.item.detail [ # 0..* Detail line items
      fhir:ClaimResponse.item.detail.detailSequence [ positiveInt ]; # 1..1 Service instance

      fhir:ClaimResponse.item.detail.noteNumber [ positiveInt ], ... ; # 0..* List of note numbers which apply
      fhir:
      fhir:
        fhir:

      fhir:ClaimResponse.item.detail.adjudication [ See ClaimResponse.item.adjudication ], ... ; # 0..* Detail level adjudication details
      fhir:ClaimResponse.item.detail.subDetail [ # 0..* Subdetail line items
        fhir:ClaimResponse.item.detail.subDetail.subDetailSequence [ positiveInt ]; # 1..1 Service instance

        fhir:ClaimResponse.item.detail.subDetail.noteNumber [ positiveInt ], ... ; # 0..* List of note numbers which apply
        fhir:

        fhir:ClaimResponse.item.detail.subDetail.adjudication [ See ClaimResponse.item.adjudication ], ... ; # 0..* Subdetail level adjudication details

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

  fhir:ClaimResponse.addItem [ # 0..* Insurer added line items
    fhir:ClaimResponse.addItem.itemSequence [ positiveInt ], ... ; # 0..* Service instances
    fhir:ClaimResponse.addItem.detailSequence [ positiveInt ], ... ; # 0..* Detail sequence number
    fhir:ClaimResponse.addItem.subdetailSequence [ positiveInt ], ... ; # 0..* Subdetail sequence number
    fhir:ClaimResponse.addItem.provider [ Reference(Practitioner|PractitionerRole|Organization) ], ... ; # 0..* Authorized providers
    fhir:ClaimResponse.addItem.billcode [ CodeableConcept ]; # 0..1 Group, Service or Product
    fhir:ClaimResponse.addItem.modifier [ CodeableConcept ], ... ; # 0..* Service/Product billing modifiers
    fhir:ClaimResponse.addItem.programCode [ CodeableConcept ], ... ; # 0..* Program specific reason for item inclusion
    # ClaimResponse.addItem.serviced[x] : 0..1 Date or dates of Service. One of these 2
      fhir:ClaimResponse.addItem.servicedDate [ date ]
      fhir:ClaimResponse.addItem.servicedPeriod [ Period ]
    # ClaimResponse.addItem.location[x] : 0..1 Place of service. 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 point
    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 Service Location
    fhir:ClaimResponse.addItem.subSite [ CodeableConcept ], ... ; # 0..* Service Sub-location

    fhir:ClaimResponse.addItem.noteNumber [ positiveInt ], ... ; # 0..* List of note numbers which apply
    fhir:
    fhir:
      fhir:
      fhir:
      fhir:
      fhir:
      fhir:

    fhir:ClaimResponse.addItem.adjudication [ See ClaimResponse.item.adjudication ], ... ; # 0..* Added items adjudication
    fhir:ClaimResponse.addItem.detail [ # 0..* Insurer added line items
      fhir:ClaimResponse.addItem.detail.billcode [ CodeableConcept ]; # 0..1 Group, Service or Product
      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 point
      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..* List of note numbers which apply
      fhir:

      fhir:ClaimResponse.addItem.detail.adjudication [ See ClaimResponse.item.adjudication ], ... ; # 0..* Added items detail adjudication
      fhir:ClaimResponse.addItem.detail.subDetail [ # 0..* Insurer added line items
        fhir:ClaimResponse.addItem.detail.subDetail.billcode [ CodeableConcept ]; # 0..1 Group, Service or Product
        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 point
        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..* List of note numbers which apply
        fhir:ClaimResponse.addItem.detail.subDetail.adjudication [ See ClaimResponse.item.adjudication ], ... ; # 0..* Added items detail adjudication
      ], ...;

    ], ...;
  ], ...;
  fhir:ClaimResponse.error [ # 0..* Processing errors
    fhir:
    fhir:
    fhir:
    fhir:

    fhir:ClaimResponse.error.itemSequence [ positiveInt ]; # 0..1 Item sequence number
    fhir:ClaimResponse.error.detailSequence [ positiveInt ]; # 0..1 Detail sequence number
    fhir:ClaimResponse.error.subDetailSequence [ positiveInt ]; # 0..1 Subdetail sequence number
    fhir:ClaimResponse.error.code [ CodeableConcept ]; # 1..1 Error code detailing processing issues

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

  fhir:ClaimResponse.total [ # 0..* Adjudication totals
    fhir:ClaimResponse.total.category [ CodeableConcept ]; # 1..1 Adjudication category such as submitted, co-pay, eligible, benefit, etc.
    fhir:ClaimResponse.total.amount [ Money ]; # 1..1 Monetary amount
  ], ...;
  fhir:ClaimResponse.payment [ # 0..1 Payment Details

    fhir:ClaimResponse.payment.type [ CodeableConcept ]; # 0..1 Partial or Complete
    fhir:ClaimResponse.payment.adjustment [ Money ]; # 0..1 Payment adjustment for non-Claim issues
    fhir:ClaimResponse.payment.adjustmentReason [ CodeableConcept ]; # 0..1 Explanation for the non-claim adjustment
    fhir:ClaimResponse.payment.date [ date ]; # 0..1 Expected data of Payment
    fhir:ClaimResponse.payment.amount [ Money ]; # 0..1 Payable amount after adjustment
    fhir:ClaimResponse.payment.identifier [ Identifier ]; # 0..1 Identifier of the payment instrument
  ];
  fhir:ClaimResponse.reserved [ Coding ]; # 0..1 Funds reserved status
  fhir:ClaimResponse.form [ CodeableConcept ]; # 0..1 Printed Form Identifier
  fhir:ClaimResponse.processNote [ # 0..* Processing notes
    fhir:ClaimResponse.processNote.number [ positiveInt ]; # 0..1 Sequence Number for this note
    fhir:

    fhir:ClaimResponse.processNote.type [ code ]; # 0..1 display | print | printoper

    fhir:ClaimResponse.processNote.text [ string ]; # 0..1 Note explanatory text
    fhir:ClaimResponse.processNote.language [ CodeableConcept ]; # 0..1 Language if different from the resource
  ], ...;
  fhir:ClaimResponse.communicationRequest [ Reference(CommunicationRequest) ], ... ; # 0..* Request for additional information
  fhir:ClaimResponse.insurance [ # 0..* Insurance or medical plan
    fhir:ClaimResponse.insurance.sequence [ positiveInt ]; # 1..1 Service instance identifier
    fhir:ClaimResponse.insurance.focal [ boolean ]; # 1..1 Is the focal Coverage
    fhir:ClaimResponse.insurance.coverage [ Reference(Coverage) ]; # 1..1 Insurance information
    fhir:ClaimResponse.insurance.businessArrangement [ string ]; # 0..1 Business agreement
    fhir:

    fhir:ClaimResponse.insurance.claimResponse [ Reference(ClaimResponse) ]; # 0..1 Adjudication results
  ], ...;
]

Changes since DSTU2 Release 3

ClaimResponse.item.adjudication.amount Type changed from Quantity{http://hl7.org/fhir/StructureDefinition/Money} to Money ClaimResponse.item.detail.adjudication Remove BackboneElement ClaimResponse.item.detail.subDetail.adjudication Remove BackboneElement ClaimResponse.addItem.service Min Cardinality changed from 1 to 0 Type changed from Coding to CodeableConcept ClaimResponse.addItem.fee Type changed from Quantity{http://hl7.org/fhir/StructureDefinition/Money} to Money ClaimResponse.addItem.adjudication Remove BackboneElement ClaimResponse.addItem.detail.service Min Cardinality changed from 1 to 0 Type changed from Coding to CodeableConcept ClaimResponse.addItem.detail.fee Type changed from Quantity{http://hl7.org/fhir/StructureDefinition/Money} to Money ClaimResponse.addItem.detail.adjudication Remove BackboneElement ClaimResponse.error.code Type changed from Coding to CodeableConcept Remove Binding http://hl7.org/fhir/ValueSet/adjudication-error (required)
ClaimResponse
ClaimResponse.status ClaimResponse.type
  • Added Element
ClaimResponse.patient ClaimResponse.subType
  • Added Element
ClaimResponse.insurer ClaimResponse.use
  • Added Element
ClaimResponse.outcome ClaimResponse.requestProvider
  • Type changed from code Reference(Practitioner) to CodeableConcept Remove Binding http://hl7.org/fhir/ValueSet/remittance-outcome (required) Reference(Practitioner|PractitionerRole|Organization)
ClaimResponse.payeeType ClaimResponse.outcome
  • Type changed from Coding to CodeableConcept to code
  • Add Binding http://hl7.org/fhir/ValueSet/remittance-outcome (required)
ClaimResponse.item.adjudication.category ClaimResponse.preAuthRef
  • Added Element
ClaimResponse.item.adjudication.reason ClaimResponse.item.itemSequence
  • Added Element
ClaimResponse.item.detail.noteNumber ClaimResponse.item.detail.detailSequence
  • Added Element
ClaimResponse.item.detail.subDetail.noteNumber ClaimResponse.item.detail.subDetail.subDetailSequence
  • Added Element
ClaimResponse.addItem.revenue ClaimResponse.addItem.itemSequence
  • Added Element
ClaimResponse.addItem.category ClaimResponse.addItem.detailSequence
  • Added Element
ClaimResponse.addItem.modifier ClaimResponse.addItem.subdetailSequence
  • Added Element
ClaimResponse.addItem.noteNumber ClaimResponse.addItem.provider
  • Added Element
ClaimResponse.addItem.detail.revenue ClaimResponse.addItem.billcode
  • Added Element
ClaimResponse.addItem.detail.category ClaimResponse.addItem.programCode
  • Added Element
ClaimResponse.addItem.detail.modifier ClaimResponse.addItem.serviced[x]
  • Added Element
ClaimResponse.addItem.detail.noteNumber ClaimResponse.addItem.location[x]
  • Added Element
ClaimResponse.totalCost ClaimResponse.addItem.quantity
  • Type changed from Quantity{http://hl7.org/fhir/StructureDefinition/Money} to Money Added Element
ClaimResponse.unallocDeductable ClaimResponse.addItem.unitPrice
  • Type changed from Quantity{http://hl7.org/fhir/StructureDefinition/Money} to Money Added Element
ClaimResponse.totalBenefit ClaimResponse.addItem.factor
  • Type changed from Quantity{http://hl7.org/fhir/StructureDefinition/Money} to Money Added Element
ClaimResponse.payment ClaimResponse.addItem.net
  • Added Element
ClaimResponse.payment.type ClaimResponse.addItem.bodySite
  • Added Element
ClaimResponse.payment.adjustment ClaimResponse.addItem.subSite
  • Added Element
ClaimResponse.payment.adjustmentReason ClaimResponse.addItem.detail.billcode
  • Added Element
ClaimResponse.payment.date ClaimResponse.addItem.detail.quantity
  • Added Element
ClaimResponse.payment.amount ClaimResponse.addItem.detail.unitPrice
  • Added Element
ClaimResponse.payment.identifier ClaimResponse.addItem.detail.factor
  • Added Element
ClaimResponse.form ClaimResponse.addItem.detail.net
  • Type changed from Coding to CodeableConcept Remove Binding http://hl7.org/fhir/ValueSet/forms (required) Added Element
ClaimResponse.processNote ClaimResponse.addItem.detail.subDetail
  • Added Element
ClaimResponse.processNote.number ClaimResponse.addItem.detail.subDetail.billcode
  • Added Element
ClaimResponse.processNote.type ClaimResponse.addItem.detail.subDetail.modifier
  • Added Element
ClaimResponse.processNote.text ClaimResponse.addItem.detail.subDetail.quantity
  • Added Element
ClaimResponse.processNote.language ClaimResponse.addItem.detail.subDetail.unitPrice
  • Added Element
ClaimResponse.communicationRequest ClaimResponse.addItem.detail.subDetail.factor
  • Added Element
ClaimResponse.insurance ClaimResponse.addItem.detail.subDetail.net
  • Added Element
ClaimResponse.insurance.sequence ClaimResponse.addItem.detail.subDetail.noteNumber
  • Added Element
ClaimResponse.insurance.focal ClaimResponse.addItem.detail.subDetail.adjudication
  • Added Element
ClaimResponse.insurance.coverage ClaimResponse.error.itemSequence
  • Added Element
ClaimResponse.insurance.businessArrangement ClaimResponse.error.detailSequence
  • Added Element
ClaimResponse.insurance.preAuthRef ClaimResponse.error.subDetailSequence
  • Added Element
ClaimResponse.insurance.claimResponse ClaimResponse.total
  • Added Element
ClaimResponse.ruleset ClaimResponse.total.category
  • deleted Added Element
ClaimResponse.originalRuleset ClaimResponse.total.amount
  • deleted Added Element
ClaimResponse.organization ClaimResponse.processNote.type
  • deleted Type changed from CodeableConcept to code
ClaimResponse.item.adjudication.code ClaimResponse.processNote.language
  • deleted Remove Binding http://hl7.org/fhir/ValueSet/languages (extensible)
ClaimResponse.item.detail.adjudication.code ClaimResponse.requestOrganization
  • deleted
ClaimResponse.item.detail.adjudication.amount ClaimResponse.item.sequenceLinkId
  • deleted
ClaimResponse.item.detail.adjudication.value ClaimResponse.item.detail.sequenceLinkId
  • deleted
ClaimResponse.item.detail.subDetail.adjudication.code ClaimResponse.item.detail.subDetail.sequenceLinkId
  • deleted
ClaimResponse.item.detail.subDetail.adjudication.amount ClaimResponse.addItem.sequenceLinkId
  • deleted
ClaimResponse.item.detail.subDetail.adjudication.value ClaimResponse.addItem.revenue
  • deleted
ClaimResponse.addItem.noteNumberLinkId ClaimResponse.addItem.category
  • deleted
ClaimResponse.addItem.adjudication.code ClaimResponse.addItem.service
  • deleted
ClaimResponse.addItem.adjudication.amount ClaimResponse.addItem.fee
  • deleted
ClaimResponse.addItem.adjudication.value ClaimResponse.addItem.detail.revenue
  • deleted
ClaimResponse.addItem.detail.adjudication.code ClaimResponse.addItem.detail.category
  • deleted
ClaimResponse.addItem.detail.adjudication.amount ClaimResponse.addItem.detail.service
  • deleted
ClaimResponse.addItem.detail.adjudication.value ClaimResponse.addItem.detail.fee
  • deleted
ClaimResponse.paymentAdjustment ClaimResponse.error.sequenceLinkId
  • deleted
ClaimResponse.paymentAdjustmentReason ClaimResponse.error.detailSequenceLinkId
  • deleted
ClaimResponse.paymentDate ClaimResponse.error.subdetailSequenceLinkId
  • deleted
ClaimResponse.paymentAmount ClaimResponse.totalCost
  • deleted
ClaimResponse.paymentRef ClaimResponse.unallocDeductable
  • deleted
ClaimResponse.note ClaimResponse.totalBenefit
  • deleted
ClaimResponse.coverage ClaimResponse.insurance.preAuthRef
  • deleted

See the Full Difference for further information

This analysis is available as XML or JSON .

See R3 <--> R4 Conversion Maps (status = 1 test of which 1 fail to execute .)

 

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

13.7.2.1 Terminology Bindings

ClaimResponse.addItem.revenue ClaimResponse.addItem.category ClaimResponse.addItem.detail.category ClaimResponse.addItem.service ClaimResponse.addItem.detail.service ClaimResponse.addItem.modifier ClaimResponse.addItem.detail.modifier
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. Extensible ClaimTypeCodes
ClaimResponse.subType A more granulat claim typecode. Example ExampleClaimSubTypeCodes
ClaimResponse.use Claim, preauthorization, predetermination. Required Use
ClaimResponse.outcome The result of the claim processing processing. Example 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.billcode
ClaimResponse.addItem.detail.revenue ClaimResponse.addItem.detail.billcode
ClaimResponse.addItem.detail.subDetail.billcode 		Codes Allowable service and product codes. Example USCLSCodes
ClaimResponse.addItem.modifier
ClaimResponse.addItem.detail.modifier
ClaimResponse.addItem.detail.subDetail.modifier 		Item type or modifiers codes, eg for Oral whether the revenue treatment is cosmetic or cost centers supplying the service and/or products. associated with TMJ, or an appliance was lost or stolen. Example ModifierTypeCodes
ClaimResponse.addItem.programCode Program specific reason codes. Example Revenue Center Codes ExampleProgramReasonCodes
ClaimResponse.addItem.location[x] Benefit subcategories such as: oral-basic, major, glasses Place of service: pharmacy,school, prison, etc. Example Benefit SubCategory Codes ExampleServicePlaceCodes
ClaimResponse.addItem.bodySite Allowable service The code for the teeth, quadrant, sextant and product codes. arch. Example USCLS Codes OralSiteCodes
ClaimResponse.addItem.subSite Item type or modifiers codes, eg The code for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen. tooth surface and surface combinations. Example Modifier type Codes SurfaceCodes
ClaimResponse.error.code The adjudication error codes. Example Adjudication Error Codes
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.reserved For whom funds are to be reserved: (Patient, Provider, None). Example Funds Reservation Codes
ClaimResponse.form 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 Common Languages

13.7.3 Search Parameters

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

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 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 reference The Provider of the claim ClaimResponse.requestProvider
( Practitioner , Organization , PractitionerRole )
status token The status of the ClaimResponse ClaimResponse.status