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

The Response business identifier. A unique identifier assigned to this claim response.

Allows claim responses to be distinguished and referenced.

The status of the resource instance.

Need to track the status of the resource as 'draft' resources may undergo further edits while 'active' resources are immutable and may only have their status changed to 'cancelled'.

This element is labeled as a modifier because the status contains the code cancelled and entered-in-error codes that mark the response resource as not currently valid.

Patient Resource. A finer grained suite of claim type codes which may convey additional information such as Inpatient vs Outpatient and/or a specialty service.

Some jurisdictions need a finer grained claim type for routing and adjudication.

This may contain the local bill type codes, for example the US UB-04 bill type code or the CMS bill type.

A finer grained suite of claim type codes which may convey additional information such as Inpatient vs Outpatient and/or a specialty service.

Some jurisdictions need a finer grained claim type for routing and adjudication.

This may contain the local bill type codes, for example the US UB-04 bill type code or the CMS bill type.

The date when A code to indicate whether the enclosed suite nature of the request is: to request adjudication of products and services were performed previously rendered; or completed. requesting authorization and adjudication for provision in the future; or requesting the non-binding adjudication of the listed products and services which could be provided in the future.

This element is required to understand the nature of the request for adjudication.

The Insurer who produced this adjudicated response. party to whom the professional services and/or products have been supplied or are being considered and for whom actual for facast reimbursement is sought.

The patient must be supplied to the insurer so that confirmation of coverage and service hstory may be considered as part of the authorization and/or adjudiction.

The practitioner who is responsible date this resource was created.

Need to record a timestamp for use by both the services rendered to recipient and the patient. issuer.

The party responsible for authorization, adjudication and reimbursement.

To be a valid claim, preauthorization or predetermination there must be a party who is responsible for adjudicating the contents against a policy which provides benefits for the patient.

The organization provider which is responsible for the services rendered to the patient. claim, predetermination or preauthorization.

Typically this field would be 1..1 where this party is responsible for the claim but not necessarily professionally responsible for the provision of the individual products and services listed below.

Original request resource referrence. reference.

Processing The outcome errror, partial of the claim, predetermination, or complete preauthorization processing.

To advise the requestor of an overall processing outcome.

The resource may be used to indicate that: the request has been held (queued) for processing; that it has been processed and errors found (error); that no errors were found and that some of the adjudication has been undertaken (partial) or that all of the adjudication has been undertaken (complete).

A human readable description of the status of the adjudication.

Provided for user display.

Reference from the Insurer which is used in later communications which refers to this adjudication.

On subsequent claims, the insurer may require the provider to quote this value.

This value is only present on preauthorization adjudications.

The time frame during which this authorization is effective.

To convey to the provider when the authorized products and services must be supplied for the authorized adjudication to apply.

Type of Party to be reimbursed: Subscriber, subscriber, provider, other.

Need to know who should receive payment with the most common situations being the Provider (assignment of benefits) or the Subscriber.

The first tier service adjudications for submitted services. A claim line. Either a simple (a product or service) or a 'group' of details which can also be a simple items or groups of sub-details.

The adjudication for items provided on the claim.

A service line number. number to uniquely reference the claim item entries.

Necessary to provide a mechanism to link the adjudication result to the submitted claim item.

A list of note references The numbers associated with notes below which apply to the notes provided below. adjudication of this item.

Provides a condensed manner for associating human readable descriptive explanations for adjudications on the line item.

The If this item is a group then the values here are a summary of the adjudication results. of the detail items. If this item is a simple product or service then this is the result of the adjudication of this item.

The adjudication results conveys the insurer's assessment of the item provided in the claim under the terms of the patient's insurance coverage.

Code indicating: Co-Pay, deductible, eligible, benefit, tax, etc. A code to indicate the information type of this adjudication record. Information types may include the value submitted, maximum values or percentages allowed or payable under the plan, amounts that: the patient is responsible for in aggregate or pertaining to this item; amounts paid by other coverages; and, the benefit payable for this item.

Needed to enable understanding of the context of the other information in the adjudication.

For example codes indicating: Co-Pay, deductible, eligible, benefit, tax, etc.

Adjudication reason such as limit reached. A code supporting the understanding of the adjudication result and explaining variance from expected amount.

To support understanding of variance from adjudication expectations.

For example may indicate that the funds for this benefit type have been exhausted.

Monetary amount associated with the code. category.

Most adjuciation categories convey a monetary amount.

For example: amount submitted, eligible amount, co-payment, and benefit payable.

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

Some adjudication categories convey a percentage or a fixed value.

For example: eligible percentage or co-payment percentage.

The second tier service adjudications for submitted services. A claim detail. Either a simple (a product or service) or a 'group' of sub-details which are simple items.

The adjudication for details provided on the claim.

A service line number. number to uniquely reference the claim detail entry.

Necessary to provide a mechanism to link the adjudication result to the submitted claim detail.

A list of note references The numbers associated with notes below which apply to the notes provided below. adjudication of this item.

Provides a condensed manner for associating human readable descriptive explanations for adjudications on the line item.

The adjudications adjudication results.

The third tier service adjudications for submitted services. A sub-detail adjudication of a simple product or service.

The adjudication for sub-details provided on the claim.

A service line number. number to uniquely reference the claim sub-detail entry.

Necessary to provide a mechanism to link the adjudication result to the submitted claim sub-detail.

A list of note references The numbers associated with notes below which apply to the notes provided below. adjudication of this item.

Provides a condensed manner for associating human readable descriptive explanations for adjudications on the line item.

The adjudications adjudication results.

The first tier first-tier service adjudications for payor added services. product or service lines.

Insurers may redefine the provided product or service or may package and/or decompose groups of products and services. The addItems allows the insurer to provide their line item list with linkage to the submitted items/details/sub-details. In a preauthorization the insurer may use the addItem structure to provide additional information on authorized products and services.

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

Provides references to the claim items.

The type sequence number of reveneu or cost center providing the product and/or service. details within the claim item which this line is intended to replace.

Provides references to the claim details within the claim item.

The sequence number of the sub-details within the details within the claim item which this line is intended to replace.

Provides references to the claim sub-details within the claim detail.

Health Care Service The providers who are authorized for the services rendered to the patient.

Insurer may provide authorization specifically to identify a restricted set of providers rather than an open authorization.

When the classification value is a group code then this item collects a set of service related claim details, otherwise this contains the product, service, drug or benefits. other billing code for the item.

Necessary to state what was provided or done.

If this is an actual service or product line, i.e. not a Group, then use code to indicate the Professional Service or Product supplied (e.g. CTP, HCPCS, USCLS, ICD10, NCPDP, DIN, RxNorm, ACHI, CCI). If a grouping item then use a group code to indicate the type of thing being grouped e.g. 'glasses' or 'compound'.

A code Item typification or modifiers codes to indicate convey additional context for the Professional Service product or Product supplied. service.

To support inclusion of the item for adjudication or to charge an elevated fee.

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

Identifies the program under which this may be recovered.

May impact Commonly used in in the identification of publicly provided program focused on adjudication. population segments or disease classifications.

For example: Neonatal program, child dental program or drug users recovery program.

The fee charged for date or dates when the professional service or product.. product was supplied, performed or completed.

Needed to determine whether the service or product was provided during the term of the insurance coverage.

A list of note references to Where the notes provided below. product or service was provided.

The location can alter whether the item was acceptable for insurance purposes or impact the determination of the benefit amount.

The adjudications results. number of repetitions of a service or product.

Required when the product or service code does not convey the quantity provided.

The second tier service adjudications If the item is not a group then this is the fee for payor added services. the product or service, otherwise this is the total of the fees for the details of the group.

The amount charged to the patient by the provider for a single unit.

A real number that represents a multiplier used in determining the overall value of services delivered and/or goods received. The type concept of reveneu a Factor allows for a discount or cost center providing surcharge multiplier to be applied to a monetary amount.

When discounts are provided to a patient (example: Senior's discount) then this must be documented for adjudication.

To show a 10% senior's discount, the value entered is: 0.90 (1.00 - 0.10).

The quantity times the unit price for an additional service or product and/or service. or charge.

Provides the total amount claimed for the group (if a grouper) or the line item.

For example, the formula: quantity * unitPrice * factor = net. Quantity and factor are assumed to be 1 if not supplied.

Physical service site on the patient (limb, tooth, etc.).

Allows insurer to validate specific procedures.

For example: Providing a tooth code allows an insurer to identify a provider performing a filling on a tooth that was previously removed.

Health Care Service Type Codes to identify the classification A region or surface of service the bodySite, e.g. limb region or benefits. tooth surface(s).

Allows insurer to validate specific procedures.

A code The numbers associated with notes below which apply to indicate the Professional Service adjudication of this item.

Provides a condensed manner for associating human readable descriptive explanations for adjudications on the line item.

The adjudication results.

The second-tier service adjudications for payor added services.

When the value is a group code then this item collects a set of related claim details, otherwise this contains the product, service, drug or Product supplied. other billing code for the item.

Necessary to state what was provided or done.

If this is an actual service or product line, i.e. not a Group, then use code to indicate the Professional Service or Product supplied (e.g. CTP, HCPCS, USCLS, ICD10, NCPDP, DIN, RxNorm, ACHI, CCI). If a grouping item then use a group code to indicate the type of thing being grouped e.g. 'glasses' or 'compound'.

Item typification or modifiers codes, eg codes to convey additional context for the product or service.

To support inclusion of the item for adjudication or to charge an elevated fee.

For example in Oral whether the treatment is cosmetic or associated with TMJ, or for medical Medical whether the treatment was outside the clinic or out outside of office hours.

The number of repetitions of a service or product.

Required when the product or service code does not convey the quantity provided.

If the item is not a group then this is the fee for the product or service, otherwise this is the total of the fees for the details of the group.

May impact on adjudication. The amount charged to the patient by the provider for a single unit.

A real number that represents a multiplier used in determining the overall value of services delivered and/or goods received. The fee charged concept of a Factor allows for a discount or surcharge multiplier to be applied to a monetary amount.

When discounts are provided to a patient (example: Senior's discount) then this must be documented for adjudication.

To show a 10% senior's discount, the professional value entered is: 0.90 (1.00 - 0.10).

The quantity times the unit price for an additional service or product.. product or charge.

Provides the total amount claimed for the group (if a grouper) or the line item.

For example, the formula: quantity * unitPrice * factor = net. Quantity and factor are assumed to be 1 if not supplied.

A list of note references The numbers associated with notes below which apply to the notes provided below. adjudication of this item.

Provides a condensed manner for associating human readable descriptive explanations for adjudications on the line item.

The adjudications adjudication results.

Mutually exclusive with Services Provided (Item). The third-tier service adjudications for payor added services.

The sequence number of When the line value is a group code then this item submitted which collects a set of related claim details, otherwise this contains the error. This value is omitted when product, service, drug or other billing code for the error is elsewhere. item.

Necessary to state what was provided or done.

If this is an actual service or product line, i.e. not a Group, then use code to indicate the Professional Service or Product supplied (e.g. CTP, HCPCS, USCLS, ICD10, NCPDP, DIN, RxNorm, ACHI, CCI). If a grouping item then use a group code to indicate the type of thing being grouped e.g. 'glasses' or 'compound'.

The sequence number of Item typification or modifiers codes to convey additional context for the addition within product or service.

To support inclusion of the line item submitted which contains for adjudication or to charge an elevated fee.

For example in Oral whether the error. This value treatment is omitted when cosmetic or associated with TMJ, or for Medical whether the error is not related to an Addition. treatment was outside the clinic or outside of office hours.

The number of repetitions of a service or product.

Required when the product or service code does not convey the quantity provided.

The sequence number of the addition within If the line item submitted which contains the error. This value is omitted when not a group then this is the error fee for the product or service, otherwise this is not related to an Addition. the total of the fees for the details of the group.

The amount charged to the patient by the provider for a single unit.

An error code,from A real number that represents a specified code system, which details why multiplier used in determining the claim could not overall value of services delivered and/or goods received. The concept of a Factor allows for a discount or surcharge multiplier to be adjudicated. applied to a monetary amount.

When discounts are provided to a patient (example: Senior's discount) then this must be documented for adjudication.

To show a 10% senior's discount, the value entered is: 0.90 (1.00 - 0.10).

The total cost of quantity times the services reported. unit price for an additional service or product or charge.

This is Provides the total amount claimed for the group (if a check value that grouper) or the receiver calculates line item.

For example, the formula: quantity * unitPrice * factor = net. Quantity and returns. factor are assumed to be 1 if not supplied.

The amount of deductible applied numbers associated with notes below which was not allocated apply to any particular service line. the adjudication of this item.

Provides a condensed manner for associating human readable descriptive explanations for adjudications on the line item.

Total amount of benefit The adjudication results.

The adjudication results which are presented at the header level rather than at the line-item or add-item levels.

Some insurers will receive line-items but provide the adjudication only at a summary or header-level.

Categorized monetary totals for the adjudication.

To provide the requestor with financial totals by category for the adjudication.

Totals for amounts submitted, co-pays, benefits payable (Equal etc.

A code to sum indicate the information type of this adjudication record. Information types may include: the Benefit value submitted, maximum values or percentages allowed or payable under the plan, amounts from all detail lines that the patient is responsible for in aggregate or pertaining to this item, amounts paid by other coverages, and additions less the Unallocated Deductible). benefit payable for this item.

Needed to convey the type of total provided.

For example codes indicating: Co-Pay, deductible, eligible, benefit, tax, etc.

Monetary total amount associated with the category.

Needed to convey the total monetary amount.

Payment details for the claim if adjudication of the claim has been paid. claim.

Needed to convey references to the financial instrument that has been used if payment has been made.

Whether this represents partial or complete payment of the claim. benefits payable.

To advise the requestor when the insurer believes all payments to have been completed.

Adjustment Total amount of all adjustments to the this payment of included in this transaction which is are not related to adjudication of this transaction. claim's adjudication.

To advise the requestor of adjustments applied to the payment.

Insurers will deduct amounts owing from the provider (adjustment), such as a prior overpayment, from the amount owing to the provider (benefits payable) when payment is made to the provider.

Reason for the payment adjustment.

Needed to clarify the monetary adjustment.

Estimated date the payment data. will be issued or the actual issue date of payment.

To advise the payee when payment can be expected.

Payable Benefits payable less any payment adjustment.

Needed to provide the actual payment amount.

Payment identifier. Issuer's unique identifier for the payment instrument.

Enable the receiver to reconcile when payment received.

For example: EFT number or check number.

Status of funds reservation (For provider, A code, used only on a response to a preauthorization, to indicate whether the benefits payable have been reserved and for Patient, None). whom.

Needed to advise the submitting provider on whether the rquest for reservation of funds has been honored.

Fund would be release by a future claim quoting the preAuthRef of this response. Examples of values include: provider, patient, none.

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

Needed to specify the specific form used for producing output for this response.

May be needed to identify specific jurisdictional forms.

The actual form, by reference or inclusion, for printing the content or an EOB.

Needed to include the specific form used for producing output for this response.

Needed to permit insurers to include the actual form.

Note text. A note that describes or explains adjudication results in a human readable form.

Provides the insurer specific textual explanations associated with the processing.

An integer associated with each note which may be referred A number to from each service line item. uniquely identify a note entry.

Necessary to provide a mechanism to link from adjudications.

The business purpose of the note purpose: Print/Display. text.

To convey the expectation for when the text is used.

The note text. explanation or description associated with the processing.

Required to provide human readable explanation.

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

Note text may vary from the resource defined language.

Only required if the language is different from the resource language.

Request for additional supporting or authorizing information, such as: documents, images or resources. information.

Need to communicate insurer request for additional information required to support the adjudication.

For example: professional reports, documents, images, clinical resources, or accident reports.

Financial instrument by which payment information instruments for reimbursement for the health care. care products and services specified on the claim.

Health care programs At least one insurer is required for a claim to be a claim.

All insurance coverages for the patient which may be applicable for reimbursement, of the products and insurers services listed in the claim, are significant payors typically provided in the claim to allow insurers to confirm the ordering of health service costs. the insurance coverages relative to local 'coordination of benefit' rules. One coverage (and only one) with 'focal=true' is to be used in the adjudication of this claim. Coverages appearing before the focal Coverage in the list, and where 'subrogation=false', should provide a reference to the ClaimResponse containing the adjudication results of the prior claim.

A service line item. number to uniquely identify insurance entries and provide a sequence of coverages to convey coordination of benefit order.

To maintain order of the coverages.

The instance number of the A flag to indicate that this Coverage which is the focus to be used for adjudication. The Coverage against which the adjudication of this claim is when set to be adjudicated. true.

To identify which coverage in the list is being adjudicated. used to adjudicate this claim.

A patient may (will) have multiple insurance policies which provide reimbursement for healthcare services and products. For example a person may also be covered by their spouse's policy and both appear in the list (and may be from the same insurer). This flag will be set to true for only one of the listed policies and that policy will be used for adjudicating this claim. Other claims would be created to request adjudication against the other listed policies.

Reference to the program or plan identification, underwriter or payor. insurance card level information contained in the Coverage resource. The coverage issuing insurer will use these details to locate the patient's actual coverage within the insurer's information system.

Need Required to identify allow the issuer adjudicator to target for processing locate the correct policy and for coordination of benefit processing. history within their information system.

The contract number of a A business agreement which describes number established between the terms provider and conditions. the insurer for special business processing purposes.

Providers may have multiple business arrangements with a given insurer and must supply the specific contract number for adjudication.

A list The result of references the adjudication of the line items for the Coverage specified in this insurance.

An insurer need the adjudication results from prior insurers to determine the Insurer outstanding balance remaining by item for the items in the curent claim.

Must not be specified when 'focal=true' for this insurance.

Errors encountered during the processing of the adjudication.

Need to communicate processing issues to the requestor.

If the request contains errors then an error element should be provided and no adjudication related sections (item, addItem, or payment) should be present.

The sequence number of the line item submitted which these services pertain. contains the error. This value is omitted when the error occurs outside of the item structure.

To provide any pre-determination or prior authorization reference. Provides references to the claim items.

The Coverages adjudication details. sequence number of the detail within the line item submitted which contains the error. This value is omitted when the error occurs outside of the item structure.

Provides references to the claim details within the claim item.

The sequence number of the sub-detail within the detail within the line item submitted which contains the error. This value is omitted when the error occurs outside of the item structure.

Provides references to the claim sub-details within the claim detail.

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

Used by downstream payers Required to determine what balance remains and the net payable. convey processing errors.