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7.2 Resource ClaimResponse - Content

This resource maintained by the Financial Management Work Group

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

7.2.1 Scope and Usage

The ClaimResponse resource provides application level error or application level adjudication results which are the result of processing a submitted disciplineClaim 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: OralHealthClaim, VisionClaim etc. and Reversals.

Todo

This resource is referenced by [Claim]

7.2.2 Resource Content

Structure

Name Flags Card. Type Description & Constraints doco
. . ClaimResponse DomainResource Remittance resource
. . . identifier 0..* Identifier Response number
. . . request 0..1 Claim Id of resource triggering adjudication
. . . ruleset 0..1 Coding Resource version
Ruleset ( Example )
. . . originalRuleset 0..1 Coding Original version
Ruleset ( Example )
. . . created 0..1 dateTime Creation date
. . . organization 0..1 Organization Insurer
. . . requestProvider 0..1 Practitioner Responsible practitioner
. . . requestOrganization 0..1 Organization Responsible organization
. . . outcome 0..1 code complete | error
RemittanceOutcome ( Required )
. . . disposition 0..1 string Disposition Message
. . . payeeType 0..1 Coding Party to be paid any benefits payable
PayeeType ( Example )
. . . item 0..* Element Line items
. . . . sequenceLinkId 1..1 integer Service instance
. . . . noteNumber 0..* integer List of note numbers which apply
. . . . adjudication 0..* Element Adjudication details
. . . . . code 1..1 Coding Adjudication category such as co-pay, eligible, benefit, etc.
Adjudication ( Required )
. . . . . amount 0..1 Money Monitary amount
. . . . . value 0..1 decimal Non-monitory value
. . . . detail 0..* Element Detail line items
. . . . . sequenceLinkId 1..1 integer Service instance
. . . . . adjudication 0..* Element Detail adjudication
. . . . . . code 1..1 Coding Adjudication category such as co-pay, eligible, benefit, etc.
Adjudication ( Required )
. . . . . . amount 0..1 Money Monitary amount
. . . . . . value 0..1 decimal Non-monitory value
. . . . . subDetail 0..* Element Subdetail line items
. . . . . . sequenceLinkId 1..1 integer Service instance
. . . . . . adjudication 0..* Element Subdetail adjudication
. . . . . . . code 1..1 Coding Adjudication category such as co-pay, eligible, benefit, etc.
Adjudication ( Required )
. . . . . . . amount 0..1 Money Monitary amount
. . . . . . . value 0..1 decimal Non-monitory value
. . . addItem 0..* Element Insurer added line items
. . . . sequenceLinkId 0..* integer Service instances
. . . . service 1..1 Coding Group, Service or Product
ServiceProduct ( Example )
. . . . fee 0..1 Money Professional fee or Product charge
. . . . noteNumberLinkId 0..* integer List of note numbers which apply
. . . . adjudication 0..* Element Added items adjudication
. . . . . code 1..1 Coding Adjudication category such as co-pay, eligible, benefit, etc.
Adjudication ( Required )
. . . . . amount 0..1 Money Monitary amount
. . . . . value 0..1 decimal Non-monitory value
. . . . detail 0..* Element Added items details
. . . . . service 1..1 Coding Service or Product
ServiceProduct ( Example )
. . . . . fee 0..1 Money Professional fee or Product charge
. . . . . adjudication 0..* Element Added items detail adjudication
. . . . . . code 1..1 Coding Adjudication category such as co-pay, eligible, benefit, etc.
Adjudication ( Required )
. . . . . . amount 0..1 Money Monitary amount
. . . . . . value 0..1 decimal Non-monitory value
. . . error 0..* Element Processing errors
. . . . sequenceLinkId 0..1 integer Item sequence number
. . . . detailSequenceLinkId 0..1 integer Detail sequence number
. . . . subdetailSequenceLinkId 0..1 integer Subdetail sequence number
. . . . code 1..1 Coding Error code detailing processing issues
AdjudicationError ( Required )
. . . totalCost 0..1 Money Total Cost of service from the Claim
. . . unallocDeductable 0..1 Money Unallocated deductable
. . . totalBenefit 0..1 Money Total benefit payable for the Claim
. . . paymentAdjustment 0..1 Money Payment adjustment for non-Claim issues
. . . paymentAdjustmentReason 0..1 Coding Reason for Payment adjustment
AdjustmentReason ( Required )
. . . paymentDate 0..1 date Expected data of Payment
. . . paymentAmount 0..1 Money Payment amount
. . . paymentRef 0..1 Identifier Payment identifier
. . . reserved 0..1 Coding Funds reserved status
FundsReserve ( Example )
. . . form 0..1 Coding Printed Form Identifier
Forms ( Required )
. . . note 0..* Element Processing notes
. . . . number 0..1 integer Note Number for this note
. . . . type 0..1 Coding display | print | printoper
NoteType ( Required )
. . . . text 0..1 string Note explanitory text
. . . coverage 0..* Element Insurance or medical plan
. . . . sequence 1..1 integer Service instance identifier
. . . . focal 1..1 boolean Is the focal Coverage
. . . . coverage 1..1 Coverage Insurance information
. . . . businessArrangement 0..1 string Business agreement
. . . . relationship 1..1 Coding Patient relationship to subscriber
Relationship ( Example )
. . . . preAuthRef 0..* string Pre-Authorization/Determination Reference
. . . . claimResponse 0..1 ClaimResponse Adjudication results
. . . . originalRuleset 0..1 Coding Original version
Ruleset ( Example )

UML Diagram

ClaimResponse ( DomainResource ) The Response Business Identifier identifier : Identifier 0..* Original request resource referrence request : Reference ( Claim ) 0..1 The version of the style of resource contents. This should be mapped to the allowable profiles for this and supporting resources ruleset : Coding 0..1 « ( The static and dynamic model to which contents conform, may be business version or standard and version. Ruleset ) » The style (standard) and version of the original material which was converted into this resource originalRuleset : Coding 0..1 « ( The static and dynamic model to which contents conform, may be business version or standard and version. Ruleset ) » The date when the enclosed suite of services were performed or completed created : dateTime 0..1 The Insurer who produced this adjudicated response organization : Reference ( Organization ) 0..1 The practitioner who is responsible for the services rendered to the patient requestProvider : Reference ( Practitioner ) 0..1 The organization which is responsible for the services rendered to the patient requestOrganization : Reference ( Organization ) 0..1 Transaction status: error, complete outcome : code 0..1 « The outcome of the processing. RemittanceOutcome » A description of the status of the adjudication disposition : string 0..1 Party to be reimbursed: Subscriber, provider, other payeeType : Coding 0..1 « ( A code for the party to be reimbursed. PayeeType ) » The total cost of the services reported totalCost : Money 0..1 The amount of deductable 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 Deductable) totalBenefit : Money 0..1 Adjustment to the payment of this transaction which is not related to adjudication of this transaction paymentAdjustment : Money 0..1 Reason for the payment adjustment paymentAdjustmentReason : Coding 0..1 « Adjustment reason codes AdjustmentReason » Estimated payment data paymentDate : date 0..1 Payable less any payment adjustment paymentAmount : Money 0..1 Payment identifer paymentRef : Identifier 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) FundsReserve ) » The form to be used for printing the content form : Coding 0..1 « The forms codes Forms » Items A service line number sequenceLinkId : integer 1..1 A list of note references to the notes provided below noteNumber : integer 0..* ItemAdjudication Code indicating: Co-Pay, deductable, elegible, benefit, tax, etc code : Coding 1..1 « The adjudication codes Adjudication » Monitory amount associated with the code amount : Money 0..1 A non-monitary value for example a percentage. Mutually exclusive to the amount element above value : decimal 0..1 ItemDetail A service line number sequenceLinkId : integer 1..1 DetailAdjudication Code indicating: Co-Pay, deductable, elegible, benefit, tax, etc code : Coding 1..1 « The adjudication codes Adjudication » Monitory amount associated with the code amount : Money 0..1 A non-monitary value for example a percentage. Mutually exclusive to the amount element above value : decimal 0..1 SubDetail A service line number sequenceLinkId : integer 1..1 SubdetailAdjudication Code indicating: Co-Pay, deductable, elegible, benefit, tax, etc code : Coding 1..1 « The adjudication codes Adjudication » Monitory amount associated with the code amount : Money 0..1 A non-monitary value for example a percentage. Mutually exclusive to the amount element above value : decimal 0..1 AddedItem List of input service items which this service line is intended to replace sequenceLinkId : integer 0..* A code to indicate the Professional Service or Product supplied service : Coding 1..1 « ( Allowable service and product codes ServiceProduct ) » The fee charged for the professional service or product. fee : Money 0..1 A list of note references to the notes provided below noteNumberLinkId : integer 0..* AddedItemAdjudication Code indicating: Co-Pay, deductable, elegible, benefit, tax, etc code : Coding 1..1 « The adjudication codes Adjudication » Monitory amount associated with the code amount : Money 0..1 A non-monitary value for example a percentage. Mutually exclusive to the amount element above value : decimal 0..1 AddedItemsDetail A code to indicate the Professional Service or Product supplied service : Coding 1..1 « ( Allowable service and product codes ServiceProduct ) » The fee charged for the professional service or product. fee : Money 0..1 AddedItemDetailAdjudication Code indicating: Co-Pay, deductable, elegible, benefit, tax, etc code : Coding 1..1 « The adjudication codes Adjudication » Monitory amount associated with the code amount : Money 0..1 A non-monitary value for example a percentage. Mutually exclusive to the amount element above value : decimal 0..1 Errors The sequence number of the line item submitted which contains the error. This value is ommitted when the error is elsewhere sequenceLinkId : integer 0..1 The sequence number of the addition within the line item submitted which contains the error. This value is ommitted when the error is not related to an Addition detailSequenceLinkId : integer 0..1 The sequence number of the addition within the line item submitted which contains the error. This value is ommitted when the error is not related to an Addition subdetailSequenceLinkId : integer 0..1 An error code,froma specified code system, which details why the claim could not be adjudicated code : Coding 1..1 « The error codes for adjudication processing AdjudicationError » Notes An integer associated with each note which may be referred to from each service line item number : integer 0..1 The note purpose: Print/Display type : Coding 0..1 « The presentation types of notes NoteType » The note text text : string 0..1 Coverage A service line item sequence : integer 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 ( Coverage ) 1..1 The contract number of a business agreement which describes the terms and conditions businessArrangement : string 0..1 The relationship of the patient to the subscriber relationship : Coding 1..1 « ( The code for the relationship of the patient to the subscriber Relationship ) » A list of references from the Insurer to which these services pertain preAuthRef : string 0..* The Coverages adjudication details claimResponse : Reference ( ClaimResponse ) 0..1 The style (standard) and version of the original material which was converted into this resource originalRuleset : Coding 0..1 « ( The static and dynamic model to which contents conform, may be business version or standard and version. Ruleset ) » The adjudications results adjudication 0..* The adjudications results adjudication 0..* The adjudications results adjudication 0..* The third tier service adjudications for submitted services subDetail 0..* The second tier service adjudications for submitted services detail 0..* The first tier service adjudications for submitted services item 0..* The adjudications results adjudication 0..* The adjudications results adjudication 0..* The second tier service adjudications for payor added services detail 0..* The first tier service adjudications for payor added services addItem 0..* Mutually exclusive with Services Provided (Item) error 0..* Note text note 0..* Financial instrument by which payment information for health care coverage 0..*

XML Template 

<ClaimResponse xmlns="http://hl7.org/fhir"> doco
 <!-- from Resource: id, meta, implicitRules, and language -->
 <!-- from DomainResource: text, contained, extension, and modifierExtension -->
 <identifier><!-- 0..* Identifier Response  number --></identifier>
 <request><!-- 0..1 Reference(Claim) Id of resource triggering adjudication --></request>
 <ruleset><!-- 0..1 Coding Resource version --></ruleset>
 <originalRuleset><!-- 0..1 Coding Original version --></originalRuleset>
 <created value="[dateTime]"/><!-- 0..1 Creation date -->
 <organization><!-- 0..1 Reference(Organization) Insurer --></organization>
 <requestProvider><!-- 0..1 Reference(Practitioner) Responsible practitioner --></requestProvider>
 <requestOrganization><!-- 0..1 Reference(Organization) Responsible organization --></requestOrganization>
 <outcome value="[code]"/><!-- 0..1 complete | error -->
 <disposition value="[string]"/><!-- 0..1 Disposition Message -->
 <payeeType><!-- 0..1 Coding Party to be paid any benefits payable --></payeeType>
 <item>  <!-- 0..* Line items -->
  <sequenceLinkId value="[integer]"/><!-- 1..1 Service instance -->
  <noteNumber value="[integer]"/><!-- 0..* List of note numbers which apply -->
  <adjudication>  <!-- 0..* Adjudication details -->
   <code><!-- 1..1 Coding Adjudication category such as co-pay, eligible, benefit, etc. --></code>
   <amount><!-- 0..1 Money Monitary amount --></amount>
   <value value="[decimal]"/><!-- 0..1 Non-monitory value -->
  </adjudication>
  <detail>  <!-- 0..* Detail line items -->
   <sequenceLinkId value="[integer]"/><!-- 1..1 Service instance -->
   <adjudication>  <!-- 0..* Detail adjudication -->
    <code><!-- 1..1 Coding Adjudication category such as co-pay, eligible, benefit, etc. --></code>
    <amount><!-- 0..1 Money Monitary amount --></amount>
    <value value="[decimal]"/><!-- 0..1 Non-monitory value -->
   </adjudication>
   <subDetail>  <!-- 0..* Subdetail line items -->
    <sequenceLinkId value="[integer]"/><!-- 1..1 Service instance -->
    <adjudication>  <!-- 0..* Subdetail adjudication -->
     <code><!-- 1..1 Coding Adjudication category such as co-pay, eligible, benefit, etc. --></code>
     <amount><!-- 0..1 Money Monitary amount --></amount>
     <value value="[decimal]"/><!-- 0..1 Non-monitory value -->
    </adjudication>
   </subDetail>
  </detail>
 </item>
 <addItem>  <!-- 0..* Insurer added line items -->
  <sequenceLinkId value="[integer]"/><!-- 0..* Service instances -->
  <service><!-- 1..1 Coding Group, Service or Product --></service>
  <fee><!-- 0..1 Money Professional fee or Product charge --></fee>
  <noteNumberLinkId value="[integer]"/><!-- 0..* List of note numbers which apply -->
  <adjudication>  <!-- 0..* Added items adjudication -->
   <code><!-- 1..1 Coding Adjudication category such as co-pay, eligible, benefit, etc. --></code>
   <amount><!-- 0..1 Money Monitary amount --></amount>
   <value value="[decimal]"/><!-- 0..1 Non-monitory value -->
  </adjudication>
  <detail>  <!-- 0..* Added items details -->
   <service><!-- 1..1 Coding Service or Product --></service>
   <fee><!-- 0..1 Money Professional fee or Product charge --></fee>
   <adjudication>  <!-- 0..* Added items detail adjudication -->
    <code><!-- 1..1 Coding Adjudication category such as co-pay, eligible, benefit, etc. --></code>
    <amount><!-- 0..1 Money Monitary amount --></amount>
    <value value="[decimal]"/><!-- 0..1 Non-monitory value -->
   </adjudication>
  </detail>
 </addItem>
 <error>  <!-- 0..* Processing errors -->
  <sequenceLinkId value="[integer]"/><!-- 0..1 Item sequence number -->
  <detailSequenceLinkId value="[integer]"/><!-- 0..1 Detail sequence number -->
  <subdetailSequenceLinkId value="[integer]"/><!-- 0..1 Subdetail sequence number -->
  <code><!-- 1..1 Coding Error code detailing processing issues --></code>
 </error>
 <totalCost><!-- 0..1 Money Total Cost of service from the Claim --></totalCost>
 <unallocDeductable><!-- 0..1 Money Unallocated deductable --></unallocDeductable>
 <totalBenefit><!-- 0..1 Money Total benefit payable for the Claim --></totalBenefit>
 <paymentAdjustment><!-- 0..1 Money Payment adjustment for non-Claim issues --></paymentAdjustment>
 <paymentAdjustmentReason><!-- 0..1 Coding Reason for Payment adjustment --></paymentAdjustmentReason>
 <paymentDate value="[date]"/><!-- 0..1 Expected data of Payment -->
 <paymentAmount><!-- 0..1 Money Payment amount --></paymentAmount>
 <paymentRef><!-- 0..1 Identifier Payment identifier --></paymentRef>
 <reserved><!-- 0..1 Coding Funds reserved status --></reserved>
 <form><!-- 0..1 Coding Printed Form Identifier --></form>
 <note>  <!-- 0..* Processing notes -->
  <number value="[integer]"/><!-- 0..1 Note Number for this note -->
  <type><!-- 0..1 Coding display | print | printoper --></type>
  <text value="[string]"/><!-- 0..1 Note explanitory text -->
 </note>
 <coverage>  <!-- 0..* Insurance or medical plan -->
  <sequence value="[integer]"/><!-- 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 -->
  <relationship><!-- 1..1 Coding Patient relationship to subscriber --></relationship>
  <preAuthRef value="[string]"/><!-- 0..* Pre-Authorization/Determination Reference -->
  <claimResponse><!-- 0..1 Reference(ClaimResponse) Adjudication results --></claimResponse>
  <originalRuleset><!-- 0..1 Coding Original version --></originalRuleset>
 </coverage>
</ClaimResponse>

JSON Template 

{doco
  "resourceType" : "ClaimResponse",
  // from Resource: id, meta, implicitRules, and language
  // from DomainResource: text, contained, extension, and modifierExtension
  "identifier" : [{ Identifier }], // Response  number
  "request" : { Reference(Claim) }, // Id of resource triggering adjudication
  "ruleset" : { Coding }, // Resource version
  "originalRuleset" : { Coding }, // Original version
  "created" : "<dateTime>", // Creation date
  "organization" : { Reference(Organization) }, // Insurer
  "requestProvider" : { Reference(Practitioner) }, // Responsible practitioner
  "requestOrganization" : { Reference(Organization) }, // Responsible organization
  "outcome" : "<code>", // complete | error
  "disposition" : "<string>", // Disposition Message
  "payeeType" : { Coding }, // Party to be paid any benefits payable
  "item" : [{ // Line items
    "sequenceLinkId" : <integer>, // R!  Service instance
    "noteNumber" : [<integer>], // List of note numbers which apply
    "adjudication" : [{ // Adjudication details
      "code" : { Coding }, // R!  Adjudication category such as co-pay, eligible, benefit, etc.
      "amount" : { Money }, // Monitary amount
      "value" : <decimal> // Non-monitory value
    }],
    "detail" : [{ // Detail line items
      "sequenceLinkId" : <integer>, // R!  Service instance
      "adjudication" : [{ // Detail adjudication
        "code" : { Coding }, // R!  Adjudication category such as co-pay, eligible, benefit, etc.
        "amount" : { Money }, // Monitary amount
        "value" : <decimal> // Non-monitory value
      }],
      "subDetail" : [{ // Subdetail line items
        "sequenceLinkId" : <integer>, // R!  Service instance
        "adjudication" : [{ // Subdetail adjudication
          "code" : { Coding }, // R!  Adjudication category such as co-pay, eligible, benefit, etc.
          "amount" : { Money }, // Monitary amount
          "value" : <decimal> // Non-monitory value
        }]
      }]
    }]
  }],
  "addItem" : [{ // Insurer added line items
    "sequenceLinkId" : [<integer>], // Service instances
    "service" : { Coding }, // R!  Group, Service or Product
    "fee" : { Money }, // Professional fee or Product charge
    "noteNumberLinkId" : [<integer>], // List of note numbers which apply
    "adjudication" : [{ // Added items adjudication
      "code" : { Coding }, // R!  Adjudication category such as co-pay, eligible, benefit, etc.
      "amount" : { Money }, // Monitary amount
      "value" : <decimal> // Non-monitory value
    }],
    "detail" : [{ // Added items details
      "service" : { Coding }, // R!  Service or Product
      "fee" : { Money }, // Professional fee or Product charge
      "adjudication" : [{ // Added items detail adjudication
        "code" : { Coding }, // R!  Adjudication category such as co-pay, eligible, benefit, etc.
        "amount" : { Money }, // Monitary amount
        "value" : <decimal> // Non-monitory value
      }]
    }]
  }],
  "error" : [{ // Processing errors
    "sequenceLinkId" : <integer>, // Item sequence number
    "detailSequenceLinkId" : <integer>, // Detail sequence number
    "subdetailSequenceLinkId" : <integer>, // Subdetail sequence number
    "code" : { Coding } // R!  Error code detailing processing issues
  }],
  "totalCost" : { Money }, // Total Cost of service from the Claim
  "unallocDeductable" : { Money }, // Unallocated deductable
  "totalBenefit" : { Money }, // Total benefit payable for the Claim
  "paymentAdjustment" : { Money }, // Payment adjustment for non-Claim issues
  "paymentAdjustmentReason" : { Coding }, // Reason for Payment adjustment
  "paymentDate" : "<date>", // Expected data of Payment
  "paymentAmount" : { Money }, // Payment amount
  "paymentRef" : { Identifier }, // Payment identifier
  "reserved" : { Coding }, // Funds reserved status
  "form" : { Coding }, // Printed Form Identifier
  "note" : [{ // Processing notes
    "number" : <integer>, // Note Number for this note
    "type" : { Coding }, // display | print | printoper
    "text" : "<string>" // Note explanitory text
  }],
  "coverage" : [{ // Insurance or medical plan
    "sequence" : <integer>, // R!  Service instance identifier
    "focal" : <boolean>, // R!  Is the focal Coverage
    "coverage" : { Reference(Coverage) }, // R!  Insurance information
    "businessArrangement" : "<string>", // Business agreement
    "relationship" : { Coding }, // R!  Patient relationship to subscriber
    "preAuthRef" : ["<string>"], // Pre-Authorization/Determination Reference
    "claimResponse" : { Reference(ClaimResponse) }, // Adjudication results
    "originalRuleset" : { Coding } // Original version
  }]
}

Structure

Name Flags Card. Type Description & Constraints doco
. . ClaimResponse DomainResource Remittance resource
. . . identifier 0..* Identifier Response number
. . . request 0..1 Claim Id of resource triggering adjudication
. . . ruleset 0..1 Coding Resource version
Ruleset ( Example )
. . . originalRuleset 0..1 Coding Original version
Ruleset ( Example )
. . . created 0..1 dateTime Creation date
. . . organization 0..1 Organization Insurer
. . . requestProvider 0..1 Practitioner Responsible practitioner
. . . requestOrganization 0..1 Organization Responsible organization
. . . outcome 0..1 code complete | error
RemittanceOutcome ( Required )
. . . disposition 0..1 string Disposition Message
. . . payeeType 0..1 Coding Party to be paid any benefits payable
PayeeType ( Example )
. . . item 0..* Element Line items
. . . . sequenceLinkId 1..1 integer Service instance
. . . . noteNumber 0..* integer List of note numbers which apply
. . . . adjudication 0..* Element Adjudication details
. . . . . code 1..1 Coding Adjudication category such as co-pay, eligible, benefit, etc.
Adjudication ( Required )
. . . . . amount 0..1 Money Monitary amount
. . . . . value 0..1 decimal Non-monitory value
. . . . detail 0..* Element Detail line items
. . . . . sequenceLinkId 1..1 integer Service instance
. . . . . adjudication 0..* Element Detail adjudication
. . . . . . code 1..1 Coding Adjudication category such as co-pay, eligible, benefit, etc.
Adjudication ( Required )
. . . . . . amount 0..1 Money Monitary amount
. . . . . . value 0..1 decimal Non-monitory value
. . . . . subDetail 0..* Element Subdetail line items
. . . . . . sequenceLinkId 1..1 integer Service instance
. . . . . . adjudication 0..* Element Subdetail adjudication
. . . . . . . code 1..1 Coding Adjudication category such as co-pay, eligible, benefit, etc.
Adjudication ( Required )
. . . . . . . amount 0..1 Money Monitary amount
. . . . . . . value 0..1 decimal Non-monitory value
. . . addItem 0..* Element Insurer added line items
. . . . sequenceLinkId 0..* integer Service instances
. . . . service 1..1 Coding Group, Service or Product
ServiceProduct ( Example )
. . . . fee 0..1 Money Professional fee or Product charge
. . . . noteNumberLinkId 0..* integer List of note numbers which apply
. . . . adjudication 0..* Element Added items adjudication
. . . . . code 1..1 Coding Adjudication category such as co-pay, eligible, benefit, etc.
Adjudication ( Required )
. . . . . amount 0..1 Money Monitary amount
. . . . . value 0..1 decimal Non-monitory value
. . . . detail 0..* Element Added items details
. . . . . service 1..1 Coding Service or Product
ServiceProduct ( Example )
. . . . . fee 0..1 Money Professional fee or Product charge
. . . . . adjudication 0..* Element Added items detail adjudication
. . . . . . code 1..1 Coding Adjudication category such as co-pay, eligible, benefit, etc.
Adjudication ( Required )
. . . . . . amount 0..1 Money Monitary amount
. . . . . . value 0..1 decimal Non-monitory value
. . . error 0..* Element Processing errors
. . . . sequenceLinkId 0..1 integer Item sequence number
. . . . detailSequenceLinkId 0..1 integer Detail sequence number
. . . . subdetailSequenceLinkId 0..1 integer Subdetail sequence number
. . . . code 1..1 Coding Error code detailing processing issues
AdjudicationError ( Required )
. . . totalCost 0..1 Money Total Cost of service from the Claim
. . . unallocDeductable 0..1 Money Unallocated deductable
. . . totalBenefit 0..1 Money Total benefit payable for the Claim
. . . paymentAdjustment 0..1 Money Payment adjustment for non-Claim issues
. . . paymentAdjustmentReason 0..1 Coding Reason for Payment adjustment
AdjustmentReason ( Required )
. . . paymentDate 0..1 date Expected data of Payment
. . . paymentAmount 0..1 Money Payment amount
. . . paymentRef 0..1 Identifier Payment identifier
. . . reserved 0..1 Coding Funds reserved status
FundsReserve ( Example )
. . . form 0..1 Coding Printed Form Identifier
Forms ( Required )
. . . note 0..* Element Processing notes
. . . . number 0..1 integer Note Number for this note
. . . . type 0..1 Coding display | print | printoper
NoteType ( Required )
. . . . text 0..1 string Note explanitory text
. . . coverage 0..* Element Insurance or medical plan
. . . . sequence 1..1 integer Service instance identifier
. . . . focal 1..1 boolean Is the focal Coverage
. . . . coverage 1..1 Coverage Insurance information
. . . . businessArrangement 0..1 string Business agreement
. . . . relationship 1..1 Coding Patient relationship to subscriber
Relationship ( Example )
. . . . preAuthRef 0..* string Pre-Authorization/Determination Reference
. . . . claimResponse 0..1 ClaimResponse Adjudication results
. . . . originalRuleset 0..1 Coding Original version
Ruleset ( Example )

UML Diagram

ClaimResponse ( DomainResource ) The Response Business Identifier identifier : Identifier 0..* Original request resource referrence request : Reference ( Claim ) 0..1 The version of the style of resource contents. This should be mapped to the allowable profiles for this and supporting resources ruleset : Coding 0..1 « ( The static and dynamic model to which contents conform, may be business version or standard and version. Ruleset ) » The style (standard) and version of the original material which was converted into this resource originalRuleset : Coding 0..1 « ( The static and dynamic model to which contents conform, may be business version or standard and version. Ruleset ) » The date when the enclosed suite of services were performed or completed created : dateTime 0..1 The Insurer who produced this adjudicated response organization : Reference ( Organization ) 0..1 The practitioner who is responsible for the services rendered to the patient requestProvider : Reference ( Practitioner ) 0..1 The organization which is responsible for the services rendered to the patient requestOrganization : Reference ( Organization ) 0..1 Transaction status: error, complete outcome : code 0..1 « The outcome of the processing. RemittanceOutcome » A description of the status of the adjudication disposition : string 0..1 Party to be reimbursed: Subscriber, provider, other payeeType : Coding 0..1 « ( A code for the party to be reimbursed. PayeeType ) » The total cost of the services reported totalCost : Money 0..1 The amount of deductable 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 Deductable) totalBenefit : Money 0..1 Adjustment to the payment of this transaction which is not related to adjudication of this transaction paymentAdjustment : Money 0..1 Reason for the payment adjustment paymentAdjustmentReason : Coding 0..1 « Adjustment reason codes AdjustmentReason » Estimated payment data paymentDate : date 0..1 Payable less any payment adjustment paymentAmount : Money 0..1 Payment identifer paymentRef : Identifier 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) FundsReserve ) » The form to be used for printing the content form : Coding 0..1 « The forms codes Forms » Items A service line number sequenceLinkId : integer 1..1 A list of note references to the notes provided below noteNumber : integer 0..* ItemAdjudication Code indicating: Co-Pay, deductable, elegible, benefit, tax, etc code : Coding 1..1 « The adjudication codes Adjudication » Monitory amount associated with the code amount : Money 0..1 A non-monitary value for example a percentage. Mutually exclusive to the amount element above value : decimal 0..1 ItemDetail A service line number sequenceLinkId : integer 1..1 DetailAdjudication Code indicating: Co-Pay, deductable, elegible, benefit, tax, etc code : Coding 1..1 « The adjudication codes Adjudication » Monitory amount associated with the code amount : Money 0..1 A non-monitary value for example a percentage. Mutually exclusive to the amount element above value : decimal 0..1 SubDetail A service line number sequenceLinkId : integer 1..1 SubdetailAdjudication Code indicating: Co-Pay, deductable, elegible, benefit, tax, etc code : Coding 1..1 « The adjudication codes Adjudication » Monitory amount associated with the code amount : Money 0..1 A non-monitary value for example a percentage. Mutually exclusive to the amount element above value : decimal 0..1 AddedItem List of input service items which this service line is intended to replace sequenceLinkId : integer 0..* A code to indicate the Professional Service or Product supplied service : Coding 1..1 « ( Allowable service and product codes ServiceProduct ) » The fee charged for the professional service or product. fee : Money 0..1 A list of note references to the notes provided below noteNumberLinkId : integer 0..* AddedItemAdjudication Code indicating: Co-Pay, deductable, elegible, benefit, tax, etc code : Coding 1..1 « The adjudication codes Adjudication » Monitory amount associated with the code amount : Money 0..1 A non-monitary value for example a percentage. Mutually exclusive to the amount element above value : decimal 0..1 AddedItemsDetail A code to indicate the Professional Service or Product supplied service : Coding 1..1 « ( Allowable service and product codes ServiceProduct ) » The fee charged for the professional service or product. fee : Money 0..1 AddedItemDetailAdjudication Code indicating: Co-Pay, deductable, elegible, benefit, tax, etc code : Coding 1..1 « The adjudication codes Adjudication » Monitory amount associated with the code amount : Money 0..1 A non-monitary value for example a percentage. Mutually exclusive to the amount element above value : decimal 0..1 Errors The sequence number of the line item submitted which contains the error. This value is ommitted when the error is elsewhere sequenceLinkId : integer 0..1 The sequence number of the addition within the line item submitted which contains the error. This value is ommitted when the error is not related to an Addition detailSequenceLinkId : integer 0..1 The sequence number of the addition within the line item submitted which contains the error. This value is ommitted when the error is not related to an Addition subdetailSequenceLinkId : integer 0..1 An error code,froma specified code system, which details why the claim could not be adjudicated code : Coding 1..1 « The error codes for adjudication processing AdjudicationError » Notes An integer associated with each note which may be referred to from each service line item number : integer 0..1 The note purpose: Print/Display type : Coding 0..1 « The presentation types of notes NoteType » The note text text : string 0..1 Coverage A service line item sequence : integer 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 ( Coverage ) 1..1 The contract number of a business agreement which describes the terms and conditions businessArrangement : string 0..1 The relationship of the patient to the subscriber relationship : Coding 1..1 « ( The code for the relationship of the patient to the subscriber Relationship ) » A list of references from the Insurer to which these services pertain preAuthRef : string 0..* The Coverages adjudication details claimResponse : Reference ( ClaimResponse ) 0..1 The style (standard) and version of the original material which was converted into this resource originalRuleset : Coding 0..1 « ( The static and dynamic model to which contents conform, may be business version or standard and version. Ruleset ) » The adjudications results adjudication 0..* The adjudications results adjudication 0..* The adjudications results adjudication 0..* The third tier service adjudications for submitted services subDetail 0..* The second tier service adjudications for submitted services detail 0..* The first tier service adjudications for submitted services item 0..* The adjudications results adjudication 0..* The adjudications results adjudication 0..* The second tier service adjudications for payor added services detail 0..* The first tier service adjudications for payor added services addItem 0..* Mutually exclusive with Services Provided (Item) error 0..* Note text note 0..* Financial instrument by which payment information for health care coverage 0..*

XML Template 

<ClaimResponse xmlns="http://hl7.org/fhir"> doco
 <!-- from Resource: id, meta, implicitRules, and language -->
 <!-- from DomainResource: text, contained, extension, and modifierExtension -->
 <identifier><!-- 0..* Identifier Response  number --></identifier>
 <request><!-- 0..1 Reference(Claim) Id of resource triggering adjudication --></request>
 <ruleset><!-- 0..1 Coding Resource version --></ruleset>
 <originalRuleset><!-- 0..1 Coding Original version --></originalRuleset>
 <created value="[dateTime]"/><!-- 0..1 Creation date -->
 <organization><!-- 0..1 Reference(Organization) Insurer --></organization>
 <requestProvider><!-- 0..1 Reference(Practitioner) Responsible practitioner --></requestProvider>
 <requestOrganization><!-- 0..1 Reference(Organization) Responsible organization --></requestOrganization>
 <outcome value="[code]"/><!-- 0..1 complete | error -->
 <disposition value="[string]"/><!-- 0..1 Disposition Message -->
 <payeeType><!-- 0..1 Coding Party to be paid any benefits payable --></payeeType>
 <item>  <!-- 0..* Line items -->
  <sequenceLinkId value="[integer]"/><!-- 1..1 Service instance -->
  <noteNumber value="[integer]"/><!-- 0..* List of note numbers which apply -->
  <adjudication>  <!-- 0..* Adjudication details -->
   <code><!-- 1..1 Coding Adjudication category such as co-pay, eligible, benefit, etc. --></code>
   <amount><!-- 0..1 Money Monitary amount --></amount>
   <value value="[decimal]"/><!-- 0..1 Non-monitory value -->
  </adjudication>
  <detail>  <!-- 0..* Detail line items -->
   <sequenceLinkId value="[integer]"/><!-- 1..1 Service instance -->
   <adjudication>  <!-- 0..* Detail adjudication -->
    <code><!-- 1..1 Coding Adjudication category such as co-pay, eligible, benefit, etc. --></code>
    <amount><!-- 0..1 Money Monitary amount --></amount>
    <value value="[decimal]"/><!-- 0..1 Non-monitory value -->
   </adjudication>
   <subDetail>  <!-- 0..* Subdetail line items -->
    <sequenceLinkId value="[integer]"/><!-- 1..1 Service instance -->
    <adjudication>  <!-- 0..* Subdetail adjudication -->
     <code><!-- 1..1 Coding Adjudication category such as co-pay, eligible, benefit, etc. --></code>
     <amount><!-- 0..1 Money Monitary amount --></amount>
     <value value="[decimal]"/><!-- 0..1 Non-monitory value -->
    </adjudication>
   </subDetail>
  </detail>
 </item>
 <addItem>  <!-- 0..* Insurer added line items -->
  <sequenceLinkId value="[integer]"/><!-- 0..* Service instances -->
  <service><!-- 1..1 Coding Group, Service or Product --></service>
  <fee><!-- 0..1 Money Professional fee or Product charge --></fee>
  <noteNumberLinkId value="[integer]"/><!-- 0..* List of note numbers which apply -->
  <adjudication>  <!-- 0..* Added items adjudication -->
   <code><!-- 1..1 Coding Adjudication category such as co-pay, eligible, benefit, etc. --></code>
   <amount><!-- 0..1 Money Monitary amount --></amount>
   <value value="[decimal]"/><!-- 0..1 Non-monitory value -->
  </adjudication>
  <detail>  <!-- 0..* Added items details -->
   <service><!-- 1..1 Coding Service or Product --></service>
   <fee><!-- 0..1 Money Professional fee or Product charge --></fee>
   <adjudication>  <!-- 0..* Added items detail adjudication -->
    <code><!-- 1..1 Coding Adjudication category such as co-pay, eligible, benefit, etc. --></code>
    <amount><!-- 0..1 Money Monitary amount --></amount>
    <value value="[decimal]"/><!-- 0..1 Non-monitory value -->
   </adjudication>
  </detail>
 </addItem>
 <error>  <!-- 0..* Processing errors -->
  <sequenceLinkId value="[integer]"/><!-- 0..1 Item sequence number -->
  <detailSequenceLinkId value="[integer]"/><!-- 0..1 Detail sequence number -->
  <subdetailSequenceLinkId value="[integer]"/><!-- 0..1 Subdetail sequence number -->
  <code><!-- 1..1 Coding Error code detailing processing issues --></code>
 </error>
 <totalCost><!-- 0..1 Money Total Cost of service from the Claim --></totalCost>
 <unallocDeductable><!-- 0..1 Money Unallocated deductable --></unallocDeductable>
 <totalBenefit><!-- 0..1 Money Total benefit payable for the Claim --></totalBenefit>
 <paymentAdjustment><!-- 0..1 Money Payment adjustment for non-Claim issues --></paymentAdjustment>
 <paymentAdjustmentReason><!-- 0..1 Coding Reason for Payment adjustment --></paymentAdjustmentReason>
 <paymentDate value="[date]"/><!-- 0..1 Expected data of Payment -->
 <paymentAmount><!-- 0..1 Money Payment amount --></paymentAmount>
 <paymentRef><!-- 0..1 Identifier Payment identifier --></paymentRef>
 <reserved><!-- 0..1 Coding Funds reserved status --></reserved>
 <form><!-- 0..1 Coding Printed Form Identifier --></form>
 <note>  <!-- 0..* Processing notes -->
  <number value="[integer]"/><!-- 0..1 Note Number for this note -->
  <type><!-- 0..1 Coding display | print | printoper --></type>
  <text value="[string]"/><!-- 0..1 Note explanitory text -->
 </note>
 <coverage>  <!-- 0..* Insurance or medical plan -->
  <sequence value="[integer]"/><!-- 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 -->
  <relationship><!-- 1..1 Coding Patient relationship to subscriber --></relationship>
  <preAuthRef value="[string]"/><!-- 0..* Pre-Authorization/Determination Reference -->
  <claimResponse><!-- 0..1 Reference(ClaimResponse) Adjudication results --></claimResponse>
  <originalRuleset><!-- 0..1 Coding Original version --></originalRuleset>
 </coverage>
</ClaimResponse>

JSON Template 

{doco
  "resourceType" : "ClaimResponse",
  // from Resource: id, meta, implicitRules, and language
  // from DomainResource: text, contained, extension, and modifierExtension
  "identifier" : [{ Identifier }], // Response  number
  "request" : { Reference(Claim) }, // Id of resource triggering adjudication
  "ruleset" : { Coding }, // Resource version
  "originalRuleset" : { Coding }, // Original version
  "created" : "<dateTime>", // Creation date
  "organization" : { Reference(Organization) }, // Insurer
  "requestProvider" : { Reference(Practitioner) }, // Responsible practitioner
  "requestOrganization" : { Reference(Organization) }, // Responsible organization
  "outcome" : "<code>", // complete | error
  "disposition" : "<string>", // Disposition Message
  "payeeType" : { Coding }, // Party to be paid any benefits payable
  "item" : [{ // Line items
    "sequenceLinkId" : <integer>, // R!  Service instance
    "noteNumber" : [<integer>], // List of note numbers which apply
    "adjudication" : [{ // Adjudication details
      "code" : { Coding }, // R!  Adjudication category such as co-pay, eligible, benefit, etc.
      "amount" : { Money }, // Monitary amount
      "value" : <decimal> // Non-monitory value
    }],
    "detail" : [{ // Detail line items
      "sequenceLinkId" : <integer>, // R!  Service instance
      "adjudication" : [{ // Detail adjudication
        "code" : { Coding }, // R!  Adjudication category such as co-pay, eligible, benefit, etc.
        "amount" : { Money }, // Monitary amount
        "value" : <decimal> // Non-monitory value
      }],
      "subDetail" : [{ // Subdetail line items
        "sequenceLinkId" : <integer>, // R!  Service instance
        "adjudication" : [{ // Subdetail adjudication
          "code" : { Coding }, // R!  Adjudication category such as co-pay, eligible, benefit, etc.
          "amount" : { Money }, // Monitary amount
          "value" : <decimal> // Non-monitory value
        }]
      }]
    }]
  }],
  "addItem" : [{ // Insurer added line items
    "sequenceLinkId" : [<integer>], // Service instances
    "service" : { Coding }, // R!  Group, Service or Product
    "fee" : { Money }, // Professional fee or Product charge
    "noteNumberLinkId" : [<integer>], // List of note numbers which apply
    "adjudication" : [{ // Added items adjudication
      "code" : { Coding }, // R!  Adjudication category such as co-pay, eligible, benefit, etc.
      "amount" : { Money }, // Monitary amount
      "value" : <decimal> // Non-monitory value
    }],
    "detail" : [{ // Added items details
      "service" : { Coding }, // R!  Service or Product
      "fee" : { Money }, // Professional fee or Product charge
      "adjudication" : [{ // Added items detail adjudication
        "code" : { Coding }, // R!  Adjudication category such as co-pay, eligible, benefit, etc.
        "amount" : { Money }, // Monitary amount
        "value" : <decimal> // Non-monitory value
      }]
    }]
  }],
  "error" : [{ // Processing errors
    "sequenceLinkId" : <integer>, // Item sequence number
    "detailSequenceLinkId" : <integer>, // Detail sequence number
    "subdetailSequenceLinkId" : <integer>, // Subdetail sequence number
    "code" : { Coding } // R!  Error code detailing processing issues
  }],
  "totalCost" : { Money }, // Total Cost of service from the Claim
  "unallocDeductable" : { Money }, // Unallocated deductable
  "totalBenefit" : { Money }, // Total benefit payable for the Claim
  "paymentAdjustment" : { Money }, // Payment adjustment for non-Claim issues
  "paymentAdjustmentReason" : { Coding }, // Reason for Payment adjustment
  "paymentDate" : "<date>", // Expected data of Payment
  "paymentAmount" : { Money }, // Payment amount
  "paymentRef" : { Identifier }, // Payment identifier
  "reserved" : { Coding }, // Funds reserved status
  "form" : { Coding }, // Printed Form Identifier
  "note" : [{ // Processing notes
    "number" : <integer>, // Note Number for this note
    "type" : { Coding }, // display | print | printoper
    "text" : "<string>" // Note explanitory text
  }],
  "coverage" : [{ // Insurance or medical plan
    "sequence" : <integer>, // R!  Service instance identifier
    "focal" : <boolean>, // R!  Is the focal Coverage
    "coverage" : { Reference(Coverage) }, // R!  Insurance information
    "businessArrangement" : "<string>", // Business agreement
    "relationship" : { Coding }, // R!  Patient relationship to subscriber
    "preAuthRef" : ["<string>"], // Pre-Authorization/Determination Reference
    "claimResponse" : { Reference(ClaimResponse) }, // Adjudication results
    "originalRuleset" : { Coding } // Original version
  }]
}

 

Alternate definitions: Schema / Schematron , Resource Profile ( XML , JSON ), Questionnaire

7.2.2.1 Terminology Bindings

Path Definition Type Reference
ClaimResponse.ruleset
ClaimResponse.originalRuleset
ClaimResponse.coverage.originalRuleset 		The static and dynamic model to which contents conform, may be business version or standard and version. Example http://hl7.org/fhir/vs/ruleset
ClaimResponse.outcome The outcome of the processing. Required http://hl7.org/fhir/RS-link
ClaimResponse.payeeType A code for the party to be reimbursed. Example http://hl7.org/fhir/vs/payeetype
ClaimResponse.item.adjudication.code
ClaimResponse.item.detail.adjudication.code
ClaimResponse.item.detail.subDetail.adjudication.code
ClaimResponse.addItem.adjudication.code
ClaimResponse.addItem.detail.adjudication.code 		The adjudication codes Required http://hl7.org/fhir/vs/adjudication
ClaimResponse.addItem.service
ClaimResponse.addItem.detail.service 		Allowable service and product codes Example http://hl7.org/fhir/vs/service-uscls
ClaimResponse.error.code The error codes for adjudication processing Required http://hl7.org/fhir/vs/adjudication-error
ClaimResponse.paymentAdjustmentReason Adjustment reason codes Required http://hl7.org/fhir/vs/adjustment-reason
ClaimResponse.reserved For whom funds are to be reserved: (Patient, Provider, None) Example http://hl7.org/fhir/vs/fundsreserve
ClaimResponse.form The forms codes Required http://hl7.org/fhir/vs/forms
ClaimResponse.note.type The presentation types of notes Required http://hl7.org/fhir/NT-link
ClaimResponse.coverage.relationship The code for the relationship of the patient to the subscriber Example http://hl7.org/fhir/vs/relationship

7.2.3 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 Paths
identifier token The identity of the insurer ClaimResponse.identifier