DSTU2

This page is part of the FHIR Specification (v0.0.82: (v1.0.2: DSTU 1). 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

7.2 Resource ClaimResponse - Content

This resource maintained by the
Financial Management Work Group Maturity Level : 0 Compartments : Not linked to any defined compartments

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] claim

7.2.2 Resource Content

Structure

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

doco Documentation for this format

UML Diagram

ClaimResponse ( DomainResource ) The Response Business Identifier business identifier identifier : Identifier 0..* [0..*] Original request resource referrence request : Reference ( [0..1] « 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 [0..1] « ( The static and dynamic model to which contents conform, which may be business version or standard and version. standard/version. (Strength=Example) Ruleset ) ?? » The style (standard) and version of the original material which was converted into this resource originalRuleset : Coding 0..1 [0..1] « ( The static and dynamic model to which contents conform, which may be business version or standard and version. standard/version. (Strength=Example) Ruleset ) ?? » The date when the enclosed suite of services were performed or completed created : dateTime 0..1 [0..1] The Insurer who produced this adjudicated response organization : Reference ( [0..1] « Organization ) 0..1 » The practitioner who is responsible for the services rendered to the patient requestProvider : Reference ( [0..1] « Practitioner ) 0..1 » The organization which is responsible for the services rendered to the patient requestOrganization : Reference ( [0..1] « Organization ) 0..1 » Transaction status: error, complete outcome : code 0..1 [0..1] « The outcome of the processing. (Strength=Required) RemittanceOutcome ! » A description of the status of the adjudication disposition : string 0..1 [0..1] Party to be reimbursed: Subscriber, provider, other payeeType : Coding 0..1 [0..1] « ( A code for the party to be reimbursed. (Strength=Example) PayeeType Payee Type ) ?? » The total cost of the services reported totalCost : Quantity ( Money 0..1 ) [0..1] The amount of deductable deductible applied which was not allocated to any particular service line unallocDeductable : Quantity ( Money 0..1 ) [0..1] Total amount of benefit payable (Equal to sum of the Benefit amounts from all detail lines and additions less the Unallocated Deductable) Deductible) totalBenefit : Quantity ( Money 0..1 ) [0..1] Adjustment to the payment of this transaction which is not related to adjudication of this transaction paymentAdjustment : Quantity ( Money 0..1 ) [0..1] Reason for the payment adjustment paymentAdjustmentReason : Coding 0..1 [0..1] « Adjustment reason codes codes. (Strength=Extensible) AdjustmentReason Adjustment Reason + » Estimated payment data paymentDate : date 0..1 [0..1] Payable less any payment adjustment paymentAmount : Quantity ( Money 0..1 ) [0..1] Payment identifer identifier paymentRef : Identifier 0..1 [0..1] Status of funds reservation (For provider, for Patient, None) reserved : Coding 0..1 [0..1] « ( For whom funds are to be reserved: (Patient, Provider, None) None). (Strength=Example) FundsReserve Funds Reservation ) ?? » The form to be used for printing the content form : Coding 0..1 [0..1] « The forms codes codes. (Strength=Required) Forms Form ! » Items A service line number sequenceLinkId : integer positiveInt 1..1 [1..1] A list of note references to the notes provided below noteNumber : integer positiveInt 0..* [0..*] ItemAdjudication Code indicating: Co-Pay, deductable, elegible, deductible, eligible, benefit, tax, etc code : Coding 1..1 [1..1] « The adjudication codes codes. (Strength=Extensible) Adjudication + » Monitory Monetary amount associated with the code amount : Quantity ( Money 0..1 ) [0..1] A non-monitary non-monetary value for example a percentage. Mutually exclusive to the amount element above value : decimal 0..1 [0..1] ItemDetail A service line number sequenceLinkId : integer positiveInt 1..1 [1..1] DetailAdjudication Code indicating: Co-Pay, deductable, elegible, deductible, eligible, benefit, tax, etc code : Coding 1..1 [1..1] « The adjudication codes codes. (Strength=Extensible) Adjudication + » Monitory Monetary amount associated with the code amount : Quantity ( Money 0..1 ) [0..1] A non-monitary non-monetary value for example a percentage. Mutually exclusive to the amount element above value : decimal 0..1 [0..1] SubDetail A service line number sequenceLinkId : integer positiveInt 1..1 [1..1] SubdetailAdjudication Code indicating: Co-Pay, deductable, elegible, deductible, eligible, benefit, tax, etc code : Coding 1..1 [1..1] « The adjudication codes codes. (Strength=Extensible) Adjudication + » Monitory Monetary amount associated with the code amount : Quantity ( Money 0..1 ) [0..1] A non-monitary non-monetary value for example a percentage. Mutually exclusive to the amount element above value : decimal 0..1 [0..1] AddedItem List of input service items which this service line is intended to replace sequenceLinkId : integer positiveInt 0..* [0..*] A code to indicate the Professional Service or Product supplied service : Coding 1..1 [1..1] « ( Allowable service and product codes codes. (Strength=Example) ServiceProduct USCLS ) ?? » The fee charged for the professional service or product. fee : Quantity ( Money 0..1 ) [0..1] A list of note references to the notes provided below noteNumberLinkId : integer positiveInt 0..* [0..*] AddedItemAdjudication Code indicating: Co-Pay, deductable, elegible, deductible, eligible, benefit, tax, etc code : Coding 1..1 [1..1] « The adjudication codes codes. (Strength=Extensible) Adjudication + » Monitory Monetary amount associated with the code amount : Quantity ( Money 0..1 ) [0..1] A non-monitary non-monetary value for example a percentage. Mutually exclusive to the amount element above value : decimal 0..1 [0..1] AddedItemsDetail A code to indicate the Professional Service or Product supplied service : Coding 1..1 [1..1] « ( Allowable service and product codes codes. (Strength=Example) ServiceProduct USCLS ) ?? » The fee charged for the professional service or product. fee : Quantity ( Money 0..1 ) [0..1] AddedItemDetailAdjudication Code indicating: Co-Pay, deductable, elegible, deductible, eligible, benefit, tax, etc code : Coding 1..1 [1..1] « The adjudication codes codes. (Strength=Extensible) Adjudication + » Monitory Monetary amount associated with the code amount : Quantity ( Money 0..1 ) [0..1] A non-monitary non-monetary value for example a percentage. Mutually exclusive to the amount element above value : decimal 0..1 [0..1] Errors The sequence number of the line item submitted which contains the error. This value is ommitted omitted when the error is elsewhere sequenceLinkId : integer positiveInt 0..1 [0..1] The sequence number of the addition within the line item submitted which contains the error. This value is ommitted omitted when the error is not related to an Addition detailSequenceLinkId : integer positiveInt 0..1 [0..1] The sequence number of the addition within the line item submitted which contains the error. This value is ommitted omitted when the error is not related to an Addition subdetailSequenceLinkId : integer positiveInt 0..1 [0..1] An error code,froma specified code system, which details why the claim could not be adjudicated code : Coding 1..1 [1..1] « The error codes for adjudication processing processing. (Strength=Required) AdjudicationError Adjudication Error ! » Notes An integer associated with each note which may be referred to from each service line item number : integer positiveInt 0..1 [0..1] The note purpose: Print/Display type : Coding 0..1 [0..1] « The presentation types of notes notes. (Strength=Required) NoteType ! » The note text text : string 0..1 [0..1] Coverage A service line item sequence : integer positiveInt 1..1 [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 [1..1] Reference to the program or plan identification, underwriter or payor coverage : Reference ( [1..1] « Coverage ) 1..1 » The contract number of a business agreement which describes the terms and conditions businessArrangement : string 0..1 [0..1] The relationship of the patient to the subscriber relationship : Coding 1..1 [1..1] « ( The code for the relationship of the patient to the subscriber subscriber. (Strength=Example) Relationship Surface ) ?? » A list of references from the Insurer to which these services pertain preAuthRef : string 0..* [0..*] The Coverages adjudication details claimResponse : Reference ( [0..1] « ClaimResponse ) 0..1 » The style (standard) and version of the original material which was converted into this resource originalRuleset : Coding 0..1 [0..1] « ( The static and dynamic model to which contents conform, which may be business version or standard and version. standard/version. (Strength=Example) Ruleset ) ?? » The adjudications results adjudication 0..* [0..*] The adjudications results adjudication 0..* [0..*] The adjudications results adjudication 0..* [0..*] The third tier service adjudications for submitted services subDetail 0..* [0..*] The second tier service adjudications for submitted services detail 0..* [0..*] The first tier service adjudications for submitted services item 0..* [0..*] The adjudications results adjudication 0..* [0..*] The adjudications results adjudication 0..* [0..*] The second tier service adjudications for payor added services detail 0..* [0..*] The first tier service adjudications for payor added services addItem 0..* [0..*] Mutually exclusive with Services Provided (Item) error 0..* [0..*] Note text note 0..* [0..*] Financial instrument by which payment information for health care coverage 0..* [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>
 <</request>

 <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>
 <
 <</organization>
 <</requestProvider>
 <</requestOrganization>
 <
 <

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

  <adjudication>  <!-- 0..* Adjudication details -->
   <</code>
   <</amount>
   <

   <code><!-- 1..1 Coding Adjudication category such as co-pay, eligible, benefit, etc. --></code>
   <amount><!-- 0..1 Quantity(Money) Monetary amount --></amount>
   <value value="[decimal]"/><!-- 0..1 Non-monetary value -->

  </adjudication>
  <detail>  <!-- 0..* Detail line items -->
   <

   <sequenceLinkId value="[positiveInt]"/><!-- 1..1 Service instance -->

   <adjudication>  <!-- 0..* Detail adjudication -->
    <</code>
    <</amount>
    <

    <code><!-- 1..1 Coding Adjudication category such as co-pay, eligible, benefit, etc. --></code>
    <amount><!-- 0..1 Quantity(Money) Monetary amount --></amount>
    <value value="[decimal]"/><!-- 0..1 Non-monetary value -->

   </adjudication>
   <subDetail>  <!-- 0..* Subdetail line items -->
    <

    <sequenceLinkId value="[positiveInt]"/><!-- 1..1 Service instance -->

    <adjudication>  <!-- 0..* Subdetail adjudication -->
     <</code>
     <</amount>
     <

     <code><!-- 1..1 Coding Adjudication category such as co-pay, eligible, benefit, etc. --></code>
     <amount><!-- 0..1 Quantity(Money) Monetary amount --></amount>
     <value value="[decimal]"/><!-- 0..1 Non-monetary value -->

    </adjudication>
   </subDetail>
  </detail>
 </item>
 <addItem>  <!-- 0..* Insurer added line items -->
  <

  <sequenceLinkId value="[positiveInt]"/><!-- 0..* Service instances -->

  <service><!-- 1..1 Coding Group, Service or Product --></service>
  <</fee>
  <

  <fee><!-- 0..1 Quantity(Money) Professional fee or Product charge --></fee>
  <noteNumberLinkId value="[positiveInt]"/><!-- 0..* List of note numbers which apply -->

  <adjudication>  <!-- 0..* Added items adjudication -->
   <</code>
   <</amount>
   <

   <code><!-- 1..1 Coding Adjudication category such as co-pay, eligible, benefit, etc. --></code>
   <amount><!-- 0..1 Quantity(Money) Monetary amount --></amount>
   <value value="[decimal]"/><!-- 0..1 Non-monetary value -->

  </adjudication>
  <detail>  <!-- 0..* Added items details -->
   <service><!-- 1..1 Coding Service or Product --></service>
   <</fee>

   <fee><!-- 0..1 Quantity(Money) Professional fee or Product charge --></fee>

   <adjudication>  <!-- 0..* Added items detail adjudication -->
    <</code>
    <</amount>
    <

    <code><!-- 1..1 Coding Adjudication category such as co-pay, eligible, benefit, etc. --></code>
    <amount><!-- 0..1 Quantity(Money) Monetary amount --></amount>
    <value value="[decimal]"/><!-- 0..1 Non-monetary value -->

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

  <sequenceLinkId value="[positiveInt]"/><!-- 0..1 Item sequence number -->
  <detailSequenceLinkId value="[positiveInt]"/><!-- 0..1 Detail sequence number -->
  <subdetailSequenceLinkId value="[positiveInt]"/><!-- 0..1 Subdetail sequence number -->

  <code><!-- 1..1 Coding Error code detailing processing issues --></code>
 </error>
 <</totalCost>
 <</unallocDeductable>
 <</totalBenefit>
 <</paymentAdjustment>

 <totalCost><!-- 0..1 Quantity(Money) Total Cost of service from the Claim --></totalCost>
 <unallocDeductable><!-- 0..1 Quantity(Money) Unallocated deductible --></unallocDeductable>
 <totalBenefit><!-- 0..1 Quantity(Money) Total benefit payable for the Claim --></totalBenefit>
 <paymentAdjustment><!-- 0..1 Quantity(Money) Payment adjustment for non-Claim issues --></paymentAdjustment>

 <paymentAdjustmentReason><!-- 0..1 Coding Reason for Payment adjustment --></paymentAdjustmentReason>
 <
 <</paymentAmount>
 <</paymentRef>

 <paymentDate value="[date]"/><!-- 0..1 Expected data of Payment -->
 <paymentAmount><!-- 0..1 Quantity(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 -->
  <
  <</type>
  <

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

 </note>
 <coverage>  <!-- 0..* Insurance or medical plan -->
  <
  <
  <</coverage>
  <

  <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 -->

  <relationship><!-- 1..1 Coding Patient relationship to subscriber --></relationship>
  <
  <</claimResponse>

  <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" : "<positiveInt>", // R!  Service instance
    "noteNumber" : ["<positiveInt>"], // List of note numbers which apply
    "adjudication" : [{ // Adjudication details
      "code" : { Coding }, // R!  Adjudication category such as co-pay, eligible, benefit, etc.
      "amount" : { Quantity(Money) }, // Monetary amount
      "value" : <decimal> // Non-monetary value

    }],
    "
      "
      "
        "
        "
        "

    "detail" : [{ // Detail line items
      "sequenceLinkId" : "<positiveInt>", // R!  Service instance
      "adjudication" : [{ // Detail adjudication
        "code" : { Coding }, // R!  Adjudication category such as co-pay, eligible, benefit, etc.
        "amount" : { Quantity(Money) }, // Monetary amount
        "value" : <decimal> // Non-monetary value

      }],
      "
        "
        "
          "
          "
          "

      "subDetail" : [{ // Subdetail line items
        "sequenceLinkId" : "<positiveInt>", // R!  Service instance
        "adjudication" : [{ // Subdetail adjudication
          "code" : { Coding }, // R!  Adjudication category such as co-pay, eligible, benefit, etc.
          "amount" : { Quantity(Money) }, // Monetary amount
          "value" : <decimal> // Non-monetary value

        }]
      }]
    }]
  }],
  "
    "

  "addItem" : [{ // Insurer added line items
    "sequenceLinkId" : ["<positiveInt>"], // Service instances

    "service" : { Coding }, // R!  Group, Service or Product
    "
    "
    "
      "
      "
      "

    "fee" : { Quantity(Money) }, // Professional fee or Product charge
    "noteNumberLinkId" : ["<positiveInt>"], // List of note numbers which apply
    "adjudication" : [{ // Added items adjudication
      "code" : { Coding }, // R!  Adjudication category such as co-pay, eligible, benefit, etc.
      "amount" : { Quantity(Money) }, // Monetary amount
      "value" : <decimal> // Non-monetary value

    }],
    "

    "detail" : [{ // Added items details

      "service" : { Coding }, // R!  Service or Product
      "
      "
        "
        "
        "

      "fee" : { Quantity(Money) }, // Professional fee or Product charge
      "adjudication" : [{ // Added items detail adjudication
        "code" : { Coding }, // R!  Adjudication category such as co-pay, eligible, benefit, etc.
        "amount" : { Quantity(Money) }, // Monetary amount
        "value" : <decimal> // Non-monetary value

      }]
    }]
  }],
  "
    "
    "
    "

  "error" : [{ // Processing errors
    "sequenceLinkId" : "<positiveInt>", // Item sequence number
    "detailSequenceLinkId" : "<positiveInt>", // Detail sequence number
    "subdetailSequenceLinkId" : "<positiveInt>", // Subdetail sequence number

    "code" : { Coding } // R!  Error code detailing processing issues
  }],
  "
  "
  "
  "

  "totalCost" : { Quantity(Money) }, // Total Cost of service from the Claim
  "unallocDeductable" : { Quantity(Money) }, // Unallocated deductible
  "totalBenefit" : { Quantity(Money) }, // Total benefit payable for the Claim
  "paymentAdjustment" : { Quantity(Money) }, // Payment adjustment for non-Claim issues

  "paymentAdjustmentReason" : { Coding }, // Reason for Payment adjustment
  "
  "
  "

  "paymentDate" : "<date>", // Expected data of Payment
  "paymentAmount" : { Quantity(Money) }, // Payment amount
  "paymentRef" : { Identifier }, // Payment identifier

  "reserved" : { Coding }, // Funds reserved status
  "form" : { Coding }, // Printed Form Identifier
  "
    "
    "
    "

  "note" : [{ // Processing notes
    "number" : "<positiveInt>", // Note Number for this note
    "type" : { Coding }, // display | print | printoper
    "text" : "<string>" // Note explanatory text

  }],
  "
    "
    "
    "
    "

  "coverage" : [{ // 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

    "relationship" : { Coding }, // R!  Patient relationship to subscriber
    "
    "

    "preAuthRef" : ["<string>"], // Pre-Authorization/Determination Reference
    "claimResponse" : { Reference(ClaimResponse) }, // Adjudication results

    "originalRuleset" : { Coding } // Original version
  }]
}

Structure

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

doco Documentation for this format

UML Diagram

ClaimResponse ( DomainResource ) The Response Business Identifier business identifier identifier : Identifier 0..* [0..*] Original request resource referrence request : Reference ( [0..1] « 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 [0..1] « ( The static and dynamic model to which contents conform, which may be business version or standard and version. standard/version. (Strength=Example) Ruleset ) ?? » The style (standard) and version of the original material which was converted into this resource originalRuleset : Coding 0..1 [0..1] « ( The static and dynamic model to which contents conform, which may be business version or standard and version. standard/version. (Strength=Example) Ruleset ) ?? » The date when the enclosed suite of services were performed or completed created : dateTime 0..1 [0..1] The Insurer who produced this adjudicated response organization : Reference ( [0..1] « Organization ) 0..1 » The practitioner who is responsible for the services rendered to the patient requestProvider : Reference ( [0..1] « Practitioner ) 0..1 » The organization which is responsible for the services rendered to the patient requestOrganization : Reference ( [0..1] « Organization ) 0..1 » Transaction status: error, complete outcome : code 0..1 [0..1] « The outcome of the processing. (Strength=Required) RemittanceOutcome ! » A description of the status of the adjudication disposition : string 0..1 [0..1] Party to be reimbursed: Subscriber, provider, other payeeType : Coding 0..1 [0..1] « ( A code for the party to be reimbursed. (Strength=Example) PayeeType Payee Type ) ?? » The total cost of the services reported totalCost : Quantity ( Money 0..1 ) [0..1] The amount of deductable deductible applied which was not allocated to any particular service line unallocDeductable : Quantity ( Money 0..1 ) [0..1] Total amount of benefit payable (Equal to sum of the Benefit amounts from all detail lines and additions less the Unallocated Deductable) Deductible) totalBenefit : Quantity ( Money 0..1 ) [0..1] Adjustment to the payment of this transaction which is not related to adjudication of this transaction paymentAdjustment : Quantity ( Money 0..1 ) [0..1] Reason for the payment adjustment paymentAdjustmentReason : Coding 0..1 [0..1] « Adjustment reason codes codes. (Strength=Extensible) AdjustmentReason Adjustment Reason + » Estimated payment data paymentDate : date 0..1 [0..1] Payable less any payment adjustment paymentAmount : Quantity ( Money 0..1 ) [0..1] Payment identifer identifier paymentRef : Identifier 0..1 [0..1] Status of funds reservation (For provider, for Patient, None) reserved : Coding 0..1 [0..1] « ( For whom funds are to be reserved: (Patient, Provider, None) None). (Strength=Example) FundsReserve Funds Reservation ) ?? » The form to be used for printing the content form : Coding 0..1 [0..1] « The forms codes codes. (Strength=Required) Forms Form ! » Items A service line number sequenceLinkId : integer positiveInt 1..1 [1..1] A list of note references to the notes provided below noteNumber : integer positiveInt 0..* [0..*] ItemAdjudication Code indicating: Co-Pay, deductable, elegible, deductible, eligible, benefit, tax, etc code : Coding 1..1 [1..1] « The adjudication codes codes. (Strength=Extensible) Adjudication + » Monitory Monetary amount associated with the code amount : Quantity ( Money 0..1 ) [0..1] A non-monitary non-monetary value for example a percentage. Mutually exclusive to the amount element above value : decimal 0..1 [0..1] ItemDetail A service line number sequenceLinkId : integer positiveInt 1..1 [1..1] DetailAdjudication Code indicating: Co-Pay, deductable, elegible, deductible, eligible, benefit, tax, etc code : Coding 1..1 [1..1] « The adjudication codes codes. (Strength=Extensible) Adjudication + » Monitory Monetary amount associated with the code amount : Quantity ( Money 0..1 ) [0..1] A non-monitary non-monetary value for example a percentage. Mutually exclusive to the amount element above value : decimal 0..1 [0..1] SubDetail A service line number sequenceLinkId : integer positiveInt 1..1 [1..1] SubdetailAdjudication Code indicating: Co-Pay, deductable, elegible, deductible, eligible, benefit, tax, etc code : Coding 1..1 [1..1] « The adjudication codes codes. (Strength=Extensible) Adjudication + » Monitory Monetary amount associated with the code amount : Quantity ( Money 0..1 ) [0..1] A non-monitary non-monetary value for example a percentage. Mutually exclusive to the amount element above value : decimal 0..1 [0..1] AddedItem List of input service items which this service line is intended to replace sequenceLinkId : integer positiveInt 0..* [0..*] A code to indicate the Professional Service or Product supplied service : Coding 1..1 [1..1] « ( Allowable service and product codes codes. (Strength=Example) ServiceProduct USCLS ) ?? » The fee charged for the professional service or product. fee : Quantity ( Money 0..1 ) [0..1] A list of note references to the notes provided below noteNumberLinkId : integer positiveInt 0..* [0..*] AddedItemAdjudication Code indicating: Co-Pay, deductable, elegible, deductible, eligible, benefit, tax, etc code : Coding 1..1 [1..1] « The adjudication codes codes. (Strength=Extensible) Adjudication + » Monitory Monetary amount associated with the code amount : Quantity ( Money 0..1 ) [0..1] A non-monitary non-monetary value for example a percentage. Mutually exclusive to the amount element above value : decimal 0..1 [0..1] AddedItemsDetail A code to indicate the Professional Service or Product supplied service : Coding 1..1 [1..1] « ( Allowable service and product codes codes. (Strength=Example) ServiceProduct USCLS ) ?? » The fee charged for the professional service or product. fee : Quantity ( Money 0..1 ) [0..1] AddedItemDetailAdjudication Code indicating: Co-Pay, deductable, elegible, deductible, eligible, benefit, tax, etc code : Coding 1..1 [1..1] « The adjudication codes codes. (Strength=Extensible) Adjudication + » Monitory Monetary amount associated with the code amount : Quantity ( Money 0..1 ) [0..1] A non-monitary non-monetary value for example a percentage. Mutually exclusive to the amount element above value : decimal 0..1 [0..1] Errors The sequence number of the line item submitted which contains the error. This value is ommitted omitted when the error is elsewhere sequenceLinkId : integer positiveInt 0..1 [0..1] The sequence number of the addition within the line item submitted which contains the error. This value is ommitted omitted when the error is not related to an Addition detailSequenceLinkId : integer positiveInt 0..1 [0..1] The sequence number of the addition within the line item submitted which contains the error. This value is ommitted omitted when the error is not related to an Addition subdetailSequenceLinkId : integer positiveInt 0..1 [0..1] An error code,froma specified code system, which details why the claim could not be adjudicated code : Coding 1..1 [1..1] « The error codes for adjudication processing processing. (Strength=Required) AdjudicationError Adjudication Error ! » Notes An integer associated with each note which may be referred to from each service line item number : integer positiveInt 0..1 [0..1] The note purpose: Print/Display type : Coding 0..1 [0..1] « The presentation types of notes notes. (Strength=Required) NoteType ! » The note text text : string 0..1 [0..1] Coverage A service line item sequence : integer positiveInt 1..1 [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 [1..1] Reference to the program or plan identification, underwriter or payor coverage : Reference ( [1..1] « Coverage ) 1..1 » The contract number of a business agreement which describes the terms and conditions businessArrangement : string 0..1 [0..1] The relationship of the patient to the subscriber relationship : Coding 1..1 [1..1] « ( The code for the relationship of the patient to the subscriber subscriber. (Strength=Example) Relationship Surface ) ?? » A list of references from the Insurer to which these services pertain preAuthRef : string 0..* [0..*] The Coverages adjudication details claimResponse : Reference ( [0..1] « ClaimResponse ) 0..1 » The style (standard) and version of the original material which was converted into this resource originalRuleset : Coding 0..1 [0..1] « ( The static and dynamic model to which contents conform, which may be business version or standard and version. standard/version. (Strength=Example) Ruleset ) ?? » The adjudications results adjudication 0..* [0..*] The adjudications results adjudication 0..* [0..*] The adjudications results adjudication 0..* [0..*] The third tier service adjudications for submitted services subDetail 0..* [0..*] The second tier service adjudications for submitted services detail 0..* [0..*] The first tier service adjudications for submitted services item 0..* [0..*] The adjudications results adjudication 0..* [0..*] The adjudications results adjudication 0..* [0..*] The second tier service adjudications for payor added services detail 0..* [0..*] The first tier service adjudications for payor added services addItem 0..* [0..*] Mutually exclusive with Services Provided (Item) error 0..* [0..*] Note text note 0..* [0..*] Financial instrument by which payment information for health care coverage 0..* [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>
 <</request>

 <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>
 <
 <</organization>
 <</requestProvider>
 <</requestOrganization>
 <
 <

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

  <adjudication>  <!-- 0..* Adjudication details -->
   <</code>
   <</amount>
   <

   <code><!-- 1..1 Coding Adjudication category such as co-pay, eligible, benefit, etc. --></code>
   <amount><!-- 0..1 Quantity(Money) Monetary amount --></amount>
   <value value="[decimal]"/><!-- 0..1 Non-monetary value -->

  </adjudication>
  <detail>  <!-- 0..* Detail line items -->
   <

   <sequenceLinkId value="[positiveInt]"/><!-- 1..1 Service instance -->

   <adjudication>  <!-- 0..* Detail adjudication -->
    <</code>
    <</amount>
    <

    <code><!-- 1..1 Coding Adjudication category such as co-pay, eligible, benefit, etc. --></code>
    <amount><!-- 0..1 Quantity(Money) Monetary amount --></amount>
    <value value="[decimal]"/><!-- 0..1 Non-monetary value -->

   </adjudication>
   <subDetail>  <!-- 0..* Subdetail line items -->
    <

    <sequenceLinkId value="[positiveInt]"/><!-- 1..1 Service instance -->

    <adjudication>  <!-- 0..* Subdetail adjudication -->
     <</code>
     <</amount>
     <

     <code><!-- 1..1 Coding Adjudication category such as co-pay, eligible, benefit, etc. --></code>
     <amount><!-- 0..1 Quantity(Money) Monetary amount --></amount>
     <value value="[decimal]"/><!-- 0..1 Non-monetary value -->

    </adjudication>
   </subDetail>
  </detail>
 </item>
 <addItem>  <!-- 0..* Insurer added line items -->
  <

  <sequenceLinkId value="[positiveInt]"/><!-- 0..* Service instances -->

  <service><!-- 1..1 Coding Group, Service or Product --></service>
  <</fee>
  <

  <fee><!-- 0..1 Quantity(Money) Professional fee or Product charge --></fee>
  <noteNumberLinkId value="[positiveInt]"/><!-- 0..* List of note numbers which apply -->

  <adjudication>  <!-- 0..* Added items adjudication -->
   <</code>
   <</amount>
   <

   <code><!-- 1..1 Coding Adjudication category such as co-pay, eligible, benefit, etc. --></code>
   <amount><!-- 0..1 Quantity(Money) Monetary amount --></amount>
   <value value="[decimal]"/><!-- 0..1 Non-monetary value -->

  </adjudication>
  <detail>  <!-- 0..* Added items details -->
   <service><!-- 1..1 Coding Service or Product --></service>
   <</fee>

   <fee><!-- 0..1 Quantity(Money) Professional fee or Product charge --></fee>

   <adjudication>  <!-- 0..* Added items detail adjudication -->
    <</code>
    <</amount>
    <

    <code><!-- 1..1 Coding Adjudication category such as co-pay, eligible, benefit, etc. --></code>
    <amount><!-- 0..1 Quantity(Money) Monetary amount --></amount>
    <value value="[decimal]"/><!-- 0..1 Non-monetary value -->

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

  <sequenceLinkId value="[positiveInt]"/><!-- 0..1 Item sequence number -->
  <detailSequenceLinkId value="[positiveInt]"/><!-- 0..1 Detail sequence number -->
  <subdetailSequenceLinkId value="[positiveInt]"/><!-- 0..1 Subdetail sequence number -->

  <code><!-- 1..1 Coding Error code detailing processing issues --></code>
 </error>
 <</totalCost>
 <</unallocDeductable>
 <</totalBenefit>
 <</paymentAdjustment>

 <totalCost><!-- 0..1 Quantity(Money) Total Cost of service from the Claim --></totalCost>
 <unallocDeductable><!-- 0..1 Quantity(Money) Unallocated deductible --></unallocDeductable>
 <totalBenefit><!-- 0..1 Quantity(Money) Total benefit payable for the Claim --></totalBenefit>
 <paymentAdjustment><!-- 0..1 Quantity(Money) Payment adjustment for non-Claim issues --></paymentAdjustment>

 <paymentAdjustmentReason><!-- 0..1 Coding Reason for Payment adjustment --></paymentAdjustmentReason>
 <
 <</paymentAmount>
 <</paymentRef>

 <paymentDate value="[date]"/><!-- 0..1 Expected data of Payment -->
 <paymentAmount><!-- 0..1 Quantity(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 -->
  <
  <</type>
  <

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

 </note>
 <coverage>  <!-- 0..* Insurance or medical plan -->
  <
  <
  <</coverage>
  <

  <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 -->

  <relationship><!-- 1..1 Coding Patient relationship to subscriber --></relationship>
  <
  <</claimResponse>

  <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" : "<positiveInt>", // R!  Service instance
    "noteNumber" : ["<positiveInt>"], // List of note numbers which apply
    "adjudication" : [{ // Adjudication details
      "code" : { Coding }, // R!  Adjudication category such as co-pay, eligible, benefit, etc.
      "amount" : { Quantity(Money) }, // Monetary amount
      "value" : <decimal> // Non-monetary value

    }],
    "
      "
      "
        "
        "
        "

    "detail" : [{ // Detail line items
      "sequenceLinkId" : "<positiveInt>", // R!  Service instance
      "adjudication" : [{ // Detail adjudication
        "code" : { Coding }, // R!  Adjudication category such as co-pay, eligible, benefit, etc.
        "amount" : { Quantity(Money) }, // Monetary amount
        "value" : <decimal> // Non-monetary value

      }],
      "
        "
        "
          "
          "
          "

      "subDetail" : [{ // Subdetail line items
        "sequenceLinkId" : "<positiveInt>", // R!  Service instance
        "adjudication" : [{ // Subdetail adjudication
          "code" : { Coding }, // R!  Adjudication category such as co-pay, eligible, benefit, etc.
          "amount" : { Quantity(Money) }, // Monetary amount
          "value" : <decimal> // Non-monetary value

        }]
      }]
    }]
  }],
  "
    "

  "addItem" : [{ // Insurer added line items
    "sequenceLinkId" : ["<positiveInt>"], // Service instances

    "service" : { Coding }, // R!  Group, Service or Product
    "
    "
    "
      "
      "
      "

    "fee" : { Quantity(Money) }, // Professional fee or Product charge
    "noteNumberLinkId" : ["<positiveInt>"], // List of note numbers which apply
    "adjudication" : [{ // Added items adjudication
      "code" : { Coding }, // R!  Adjudication category such as co-pay, eligible, benefit, etc.
      "amount" : { Quantity(Money) }, // Monetary amount
      "value" : <decimal> // Non-monetary value

    }],
    "

    "detail" : [{ // Added items details

      "service" : { Coding }, // R!  Service or Product
      "
      "
        "
        "
        "

      "fee" : { Quantity(Money) }, // Professional fee or Product charge
      "adjudication" : [{ // Added items detail adjudication
        "code" : { Coding }, // R!  Adjudication category such as co-pay, eligible, benefit, etc.
        "amount" : { Quantity(Money) }, // Monetary amount
        "value" : <decimal> // Non-monetary value

      }]
    }]
  }],
  "
    "
    "
    "

  "error" : [{ // Processing errors
    "sequenceLinkId" : "<positiveInt>", // Item sequence number
    "detailSequenceLinkId" : "<positiveInt>", // Detail sequence number
    "subdetailSequenceLinkId" : "<positiveInt>", // Subdetail sequence number

    "code" : { Coding } // R!  Error code detailing processing issues
  }],
  "
  "
  "
  "

  "totalCost" : { Quantity(Money) }, // Total Cost of service from the Claim
  "unallocDeductable" : { Quantity(Money) }, // Unallocated deductible
  "totalBenefit" : { Quantity(Money) }, // Total benefit payable for the Claim
  "paymentAdjustment" : { Quantity(Money) }, // Payment adjustment for non-Claim issues

  "paymentAdjustmentReason" : { Coding }, // Reason for Payment adjustment
  "
  "
  "

  "paymentDate" : "<date>", // Expected data of Payment
  "paymentAmount" : { Quantity(Money) }, // Payment amount
  "paymentRef" : { Identifier }, // Payment identifier

  "reserved" : { Coding }, // Funds reserved status
  "form" : { Coding }, // Printed Form Identifier
  "
    "
    "
    "

  "note" : [{ // Processing notes
    "number" : "<positiveInt>", // Note Number for this note
    "type" : { Coding }, // display | print | printoper
    "text" : "<string>" // Note explanatory text

  }],
  "
    "
    "
    "
    "

  "coverage" : [{ // 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

    "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, which may be business version or standard and version. standard/version. Example http://hl7.org/fhir/vs/ruleset Ruleset Codes
ClaimResponse.outcome The outcome of the processing. Required http://hl7.org/fhir/RS-link RemittanceOutcome
ClaimResponse.payeeType A code for the party to be reimbursed. Example http://hl7.org/fhir/vs/payeetype Payee Type Codes
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 codes. Required Extensible http://hl7.org/fhir/vs/adjudication Adjudication Codes
ClaimResponse.addItem.service
ClaimResponse.addItem.detail.service 		Allowable service and product codes codes. Example http://hl7.org/fhir/vs/service-uscls USCLS Codes
ClaimResponse.error.code The error codes for adjudication processing processing. Required http://hl7.org/fhir/vs/adjudication-error Adjudication Error Codes
ClaimResponse.paymentAdjustmentReason Adjustment reason codes codes. Required Extensible http://hl7.org/fhir/vs/adjustment-reason Adjustment Reason Codes
ClaimResponse.reserved For whom funds are to be reserved: (Patient, Provider, None) None). Example http://hl7.org/fhir/vs/fundsreserve Funds Reservation Codes
ClaimResponse.form The forms codes codes. Required http://hl7.org/fhir/vs/forms Form Codes
ClaimResponse.note.type The presentation types of notes notes. Required http://hl7.org/fhir/NT-link NoteType
ClaimResponse.coverage.relationship The code for the relationship of the patient to the subscriber subscriber. Example http://hl7.org/fhir/vs/relationship Surface Codes

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