Release 4 5

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13.7 Resource ClaimResponse - Content

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

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

13.7.1 Scope and Usage

The ClaimResponse resource provides application level adjudication results, or an application level error, which are the result of processing a submitted Claim resource where that Claim may be the functional corollary of a Claim, Predetermination or a Preauthorization.This resource is the only appropriate response to a Claim which a processing system recognizes as a Claim resource.

This is the adjudicated response to a Claim, Predetermination or Preauthorization. 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 Preauthorization no payment will actually be made however funds may be reserved to settle a claim submitted later. For Predetermination no payment will actually be made and no assurance is given that the adjudication of a claim submitted later will match the adjudication provided, for example funds may have been exhausted in the interim. Only an actual claim may be expected to result in actual payment.

The ClaimResponse resource may also be returned with the response for the submission of: Re-adjudication and Reversals.

The ClaimResponse resource is an "event" resource from a FHIR workflow perspective - see Workflow Event.

13.7.1.1 Additional Information

Additional information regarding electronic claims content and usage may be found at:

  • Financial Resource Status Lifecycle : how .status is used in the financial resources.
  • Secondary Use of Resources : how resources such as Claim, ClaimResponse and ExplanationOfBenefit may be used for reporting and data exchange for analytics, not just for eClaims exchange between providers and payors.
  • Subrogation : how eClaims may handle patient insurance coverages when another insurer rather than the provider will settle the claim and potentially recover costs against specified coverages.
  • Coordination of Benefit : how eClaims may handle multiple patient insurance coverages.
  • RealTime Exchange and Obtaining Deferred Responsess : ClaimResponses may be obtained using Polling or FHIR REST (SEARCH).
  • Attachments and Supporting Information : how eClaims may handle the provision of supporting information, whether provided by content or reference, within the eClaim resource when submitted to the payor or later in a resource which refers to the subject eClaim resource. This also includes how payors may request additional supporting information from providers.
  • 3-Tier Line Item Hierarchy : 3-tier hierarchy of Goods, products, and Services, to support simple to complex billing.
  • Tax : Tax handling of Goods, products, and Services.

13.7.2 Boundaries and Relationships

The ClaimResponse resource is used to provide the results of the adjudication and/or authorization of a set of healthcare-related products and services for a patient against the patient's insurance coverages, or to respond with what the adjudication would be for a supplied set of products or services should they be actually supplied to the patient.

The ExplanationOfBenefit resource is for reporting out to patients or transferring data to patient centered applications, such as patient health Record (PHR) application, the ExplanationOfBenefit should be used instead of the Claim and ClaimResponse resources as those resources may contain provider and payer specific information which is not appropriate for sharing with the patient.

When using the resources for reporting and transferring claims data, which may have originated in some standard other than FHIR, the Claim resource is useful if only the request side of the information exchange is of interest. If, however, both the request and the adjudication information is to be reported then the ExplanationOfBenefit should be used instead.

When responding whether the patient's coverage is inforce, whether it is valid at this or a specified date, or returning the benefit details or preauthorization requirements associated with a coverage CoverageEligibilityResponse should be used instead and be the response to a CoverageEligibilityRequest .

The eClaim domain includes a number of related resources
ClaimResponse A payor's adjudication and/or authorization response to the suite of services provided in a Claim. Typically the ClaimResponse references the Claim but does not duplicate the clinical or financial information provided in the claim.
ExplanationOfBenefit This resource combines the information from the Claim and the ClaimResponse, stripping out any provider or payor proprietary information, into a unified information model suitable for use for: patient reporting; transferring information to a Patient Health Record system; and, supporting complete claim and adjudication information exchange with regulatory and analytics organizations and other parts of the provider's organization.
Claim A suite of goods and services and insurances coverages under which adjudication or authorization is requested.
CoverageEligibilityResponse The response to a request to a payor, a CoverageEligibilityRequest , to: ascertain whether a coverage is in-force at the current or at a specified time; list the table of benefits; determine whether coverage is provided for specified categories or specific services; and whether preauthorization is required, and if so what supporting information would be required.
This resource is referenced by

13.7.3 References to this Resource

13.7.3 13.7.4 Resource Content

Structure

1..1 Money Anatomical sub-location
Name Flags Card. Type Description & Constraints doco
. . ClaimResponse TU DomainResource Response to a claim predetermination or preauthorization

Elements defined in Ancestors: id , meta , implicitRules , language , text , contained , extension , modifierExtension
. . . identifier 0..* Identifier Business Identifier for a claim response

. . status . traceNumber 0..* Identifier Number for tracking

... status ?! Σ 1..1 code active | cancelled | draft | entered-in-error
Binding: Financial Resource Status Codes ( Required )
. . . type Σ 1..1 CodeableConcept More granular claim type
Binding: Claim Type Codes ( Extensible )
. . . subType 0..1 CodeableConcept More granular claim type
Binding: Example Claim SubType Codes ( Example )
. . . use Σ 1..1 code claim | preauthorization | predetermination
Binding: Use ( Required )
. . . patient Σ 1..1 Reference ( Patient ) The recipient of the products and services
. . . created Σ 1..1 dateTime Response creation date
. . . insurer Σ 0..1 Reference ( Organization ) Party responsible for reimbursement
. . . requestor 0..1 Reference ( Practitioner | PractitionerRole | Organization ) Party responsible for the claim
. . . request Σ 0..1 Reference ( Claim ) Id of resource triggering adjudication
. . . outcome Σ 1..1 code queued | complete | error | partial
Binding: Claim Processing Codes ( Required )
. . . decision Σ 0..1 CodeableConcept Result of the adjudication
Binding: Claim Adjudication Decision Codes ( Example )
. . . disposition 0..1 string Disposition Message
. . . preAuthRef 0..1 string Preauthorization reference
. . . preAuthPeriod 0..1 Period Preauthorization reference effective period
. . . event 0..* BackboneElement Event information

. . . payeeType . type 1..1 CodeableConcept Specific event
Binding: Dates Type Codes ( Example )
.... when[x] 1..1 0..1 Occurance date or period
..... whenDateTime dateTime
..... whenPeriod Period
... payeeType 0..1 CodeableConcept Party to be paid any benefits payable
PayeeType Binding: Claim Payee Type Codes ( Example )
. . item . encounter 0..* Reference ( Encounter ) Encounters associated with the listed treatments

... diagnosisRelatedGroup 0..1 CodeableConcept Package billing code
Binding: Example Diagnosis Related Group Codes ( Example )
... item 0..* BackboneElement Adjudication for claim line items

. . . . itemSequence 1..1 positiveInt Claim item instance identifier
. . . . traceNumber 0..* Identifier Number for tracking

. . . . noteNumber 0..* positiveInt Applicable note numbers

. . . . adjudication reviewOutcome 1..* 0..1 BackboneElement Adjudication details results
. . . . . category decision 1..1 0..1 CodeableConcept Type Result of the adjudication information
Binding: Claim Adjudication Value Decision Codes ( Example )
. . . . . reason 0..1 0..* CodeableConcept Explanation Reason for result of the adjudication outcome
Binding: Claim Adjudication Decision Reason Codes ( Example )

. . . . amount . preAuthRef 0..1 string Preauthorization reference
..... preAuthPeriod 0..1 Period Preauthorization reference effective period
.... adjudication 0..* BackboneElement Monetary amount Adjudication details

. . . . value . category 1..1 CodeableConcept Type of adjudication information
Binding: Adjudication Value Codes ( Example )
..... reason 0..1 CodeableConcept Explanation of adjudication outcome
Binding: Adjudication Reason Codes ( Example )
..... amount 0..1 decimal Money Non-monetary value Monetary amount
. . . . detail . quantity 0..1 Quantity Non-monetary value
.... detail 0..* BackboneElement Adjudication for claim details

. . . . . detailSequence 1..1 positiveInt Claim detail instance identifier
. . . . . traceNumber 0..* Identifier Number for tracking

. . . . . noteNumber 0..* positiveInt Applicable note numbers

. . . . . adjudication reviewOutcome 1..* 0..1 see adjudication reviewOutcome Detail level adjudication details results
. . . . subDetail . adjudication 0..* see adjudication Detail level adjudication details

..... subDetail 0..* BackboneElement Adjudication for claim sub-details

. . . . . . subDetailSequence 1..1 positiveInt Claim sub-detail instance identifier
. . . . . . traceNumber 0..* Identifier Number for tracking

. . . . . . noteNumber 0..* positiveInt Applicable note numbers

. . . . . . adjudication reviewOutcome 0..1 see reviewOutcome Subdetail level adjudication results
...... adjudication 0..* see adjudication Subdetail level adjudication details

. . . addItem 0..* BackboneElement Insurer added line items

. . . . itemSequence 0..* positiveInt Item sequence number

.... detailSequence 0..* positiveInt Item Detail sequence number

. . . . detailSequence subdetailSequence 0..* positiveInt Detail Subdetail sequence number

. . . subdetailSequence . traceNumber 0..* positiveInt Identifier Subdetail sequence number Number for tracking

. . . . provider 0..* Reference ( Practitioner | PractitionerRole | Organization ) Authorized providers

. . . . productOrService revenue 0..1 1..1 CodeableConcept Revenue or cost center code
Binding: Example Revenue Center Codes ( Example )
.... productOrService 0..1 CodeableConcept Billing, service, product, or drug code
Binding: USCLS Codes ( Example )
. . . . productOrServiceEnd 0..1 CodeableConcept End of a range of codes
Binding: USCLS Codes ( Example )
. . . modifier . request 0..* Reference ( DeviceRequest | MedicationRequest | NutritionOrder | ServiceRequest | SupplyRequest | VisionPrescription ) Request or Referral for Service

.... modifier 0..* CodeableConcept Service/Product billing modifiers
Binding: Modifier type Codes ( Example )

. . . . programCode 0..* CodeableConcept Program the product or service is provided under
Binding: Example Program Reason Codes ( Example )

. . . . serviced[x] 0..1 Date or dates of service or product delivery
. . . . . servicedDate date
. . . . . servicedPeriod Period
. . . . location[x] 0..1 Place of service or where product was supplied
Binding: Example Service Place Codes ( Example )
. . . . . locationCodeableConcept CodeableConcept
. . . . . locationAddress Address
. . . . . locationReference Reference ( Location )
. . . . quantity 0..1 SimpleQuantity Count of products or services
. . . . unitPrice 0..1 Money Fee, charge or cost per item
. . . . factor 0..1 decimal Price scaling factor
. . . . tax 0..1 Money Total tax
. . . . net 0..1 Money Total item cost
. . . . bodySite 0..1 0..* CodeableConcept BackboneElement Anatomical location

. . . . . site 1..* CodeableReference ( BodyStructure ) Location
Binding: Oral Site Codes ( Example )

. . . . . subSite 0..* CodeableConcept Sub-location
Binding: Surface Codes ( Example )

. . . . noteNumber 0..* positiveInt Applicable note numbers

. . . . reviewOutcome 0..1 see reviewOutcome Added items adjudication results
. . . . adjudication 1..* 0..* see adjudication Added items adjudication

. . . . detail 0..* BackboneElement Insurer added line details

. . . . . productOrService traceNumber 0..* Identifier 1..1 Number for tracking

..... revenue 0..1 CodeableConcept Revenue or cost center code
Binding: Example Revenue Center Codes ( Example )
..... productOrService 0..1 CodeableConcept Billing, service, product, or drug code
Binding: USCLS Codes ( Example )
. . . . . modifier productOrServiceEnd 0..1 CodeableConcept End of a range of codes
Binding: USCLS Codes ( Example )
..... modifier 0..* CodeableConcept Service/Product billing modifiers
Binding: Modifier type Codes ( Example )

. . . . . quantity 0..1 SimpleQuantity Count of products or services
. . . . . unitPrice 0..1 Money Fee, charge or cost per item
. . . . . factor 0..1 decimal Price scaling factor
. . . . . tax 0..1 Money Total tax
. . . . . net 0..1 Money Total item cost
. . . . . noteNumber 0..* positiveInt Applicable note numbers

. . . . . adjudication reviewOutcome 1..* 0..1 see adjudication reviewOutcome Added items detail level adjudication results
. . . . subDetail . adjudication 0..* see adjudication Added items detail adjudication

..... subDetail 0..* BackboneElement Insurer added line items

. . . . . . traceNumber 0..* Identifier Number for tracking

. . . . . . productOrService revenue 0..1 1..1 CodeableConcept Revenue or cost center code
Binding: Example Revenue Center Codes ( Example )
...... productOrService 0..1 CodeableConcept Billing, service, product, or drug code
Binding: USCLS Codes ( Example )
. . . . . . productOrServiceEnd 0..1 CodeableConcept End of a range of codes
Binding: USCLS Codes ( Example )
. . . . . . modifier 0..* CodeableConcept Service/Product billing modifiers
Binding: Modifier type Codes ( Example )

. . . . . . quantity 0..1 SimpleQuantity Count of products or services
. . . . . . unitPrice 0..1 Money Fee, charge or cost per item
. . . . . . factor 0..1 decimal Price scaling factor
. . . . . . net tax 0..1 Money Total item cost tax
. . . . . noteNumber . net 0..1 Money Total item cost
...... noteNumber 0..* positiveInt Applicable note numbers

. . . . . . reviewOutcome 0..1 see reviewOutcome Added items subdetail level adjudication results
. . . . . . adjudication 1..* 0..* see adjudication Added items detail subdetail adjudication

. . . adjudication 0..* see adjudication Header-level adjudication

. . . total Σ 0..* BackboneElement Adjudication totals

. . . . category Σ 1..1 CodeableConcept Type of adjudication information
Binding: Adjudication Value Codes ( Example )
. . . . amount Σ 1..1 Money Financial total for the category
. . . payment 0..1 BackboneElement Payment Details
. . . . type 1..1 CodeableConcept Partial or complete payment
Binding: Example Payment Type Codes ( Example )
. . . . adjustment 0..1 Money Payment adjustment for non-claim issues
. . . . adjustmentReason 0..1 CodeableConcept Explanation for the adjustment
Binding: Payment Adjustment Reason Codes ( Example )
. . . . date 0..1 date Expected date of payment
. . . . amount 1..1 Money Payable amount after adjustment
. . . . identifier 0..1 Identifier Business identifier for the payment
. . . fundsReserve 0..1 CodeableConcept Funds reserved status
FundsReserve Binding: Funds Reservation Codes ( Example )
. . . formCode 0..1 CodeableConcept Printed form identifier
Forms Binding: Form Codes ( Example )
. . . form 0..1 Attachment Printed reference or actual form
. . . processNote 0..* BackboneElement Note concerning adjudication

. . . . number 0..1 positiveInt Note instance identifier
. . . . type 0..1 code CodeableConcept display | print | printoper Note purpose
Binding: NoteType ( Required Extensible )
. . . . text 1..1 string Note explanatory text
. . . . language 0..1 CodeableConcept Language of the text
Common Binding: All Languages ( Preferred but limited to AllLanguages Required )
Additional Bindings Purpose
Common Languages Starter Set

. . . communicationRequest 0..* Reference ( CommunicationRequest ) Request for additional information

. . . insurance 0..* BackboneElement Patient insurance information

. . . . sequence 1..1 positiveInt Insurance instance identifier
. . . . focal 1..1 boolean Coverage to be used for adjudication
. . . . coverage 1..1 Reference ( Coverage ) Insurance information
. . . . businessArrangement 0..1 string Additional provider contract number
. . . . claimResponse 0..1 Reference ( ClaimResponse ) Adjudication results
. . . error 0..* BackboneElement Processing errors

. . . . itemSequence 0..1 positiveInt Item sequence number
. . . . detailSequence 0..1 positiveInt Detail sequence number
. . . . subDetailSequence 0..1 positiveInt Subdetail sequence number
. . . . code Σ 1..1 CodeableConcept Error code detailing processing issues
AdjudicationError Binding: Adjudication Error Codes ( Example )
. . . . expression Σ 0..* string FHIRPath of element(s) related to issue


doco Documentation for this format icon

See the Extensions for this resource

UML Diagram ( Legend )

ClaimResponse ( DomainResource ) A unique identifier assigned to this claim response identifier : Identifier [0..*] Trace number for tracking purposes. May be defined at the jurisdiction level or between trading partners traceNumber : Identifier [0..*] The status of the resource instance (this element modifies the meaning of other elements) status : code [1..1] « A code specifying the state of the resource instance. null (Strength=Required) FinancialResourceStatusCodes ! » A finer grained suite of claim type codes which may convey additional information such as Inpatient vs Outpatient and/or a specialty service type : CodeableConcept [1..1] « The type or discipline-style of the claim. null (Strength=Extensible) ClaimTypeCodes + » A finer grained suite of claim type codes which may convey additional information such as Inpatient vs Outpatient and/or a specialty service subType : CodeableConcept [0..1] « A more granular claim typecode. null (Strength=Example) ExampleClaimSubTypeCodes ?? » A code to indicate whether the nature of the request is: to Claim - A request adjudication of products to an Insurer to adjudicate the supplied charges for health care goods and services previously rendered; or requesting authorization under the identified policy and adjudication to pay the determined Benefit amount, if any; Preauthorization - A request to an Insurer to adjudicate the supplied proposed future charges for provision in health care goods and services under the future; or requesting identified policy and to approve the non-binding adjudication of services and provide the listed products expected benefit amounts and potentially to reserve funds to pay the benefits when Claims for the indicated services are later submitted; or, Pre-determination - A request to an Insurer to adjudicate the supplied 'what if' charges for health care goods and services which could under the identified policy and report back what the Benefit payable would be provided in had the future services actually been provided use : code [1..1] « Claim, preauthorization, predetermination. null (Strength=Required) Use ! » The 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 patient : Reference [1..1] « Patient » The date this resource was created created : dateTime [1..1] The party responsible for authorization, adjudication and reimbursement insurer : Reference [1..1] [0..1] « Organization » The provider which is responsible for the claim, predetermination or preauthorization requestor : Reference [0..1] « Practitioner | PractitionerRole | Organization » Original request resource reference request : Reference [0..1] « Claim » The outcome of the claim, predetermination, or preauthorization processing outcome : code [1..1] « null (Strength=Required) ClaimProcessingCodes ! » The result of the claim processing. (Strength=Required) claim, predetermination, or preauthorization adjudication ClaimProcessingCodes ! decision : CodeableConcept [0..1] « null (Strength=Example) ClaimAdjudicationDecisionsCod... ?? » A human readable description of the status of the adjudication disposition : string [0..1] Reference from the Insurer which is used in later communications which refers to this adjudication preAuthRef : string [0..1] The time frame during which this authorization is effective preAuthPeriod : Period [0..1] Type of Party to be reimbursed: subscriber, provider, other payeeType : CodeableConcept [0..1] « null (Strength=Example) ClaimPayeeTypeCodes ?? » Healthcare encounters related to this claim encounter : Reference [0..*] « Encounter » A package billing code for the party or bundle code used to be reimbursed. group products and services to a particular health condition (such as heart attack) which is based on a predetermined grouping code system diagnosisRelatedGroup : CodeableConcept [0..1] « null (Strength=Example) Claim Payee Type ExampleDiagnosisRelatedGroupC... ?? » A code, used only on a response to a preauthorization, to indicate whether the benefits payable have been reserved and for whom fundsReserve : CodeableConcept [0..1] « For whom funds are to be reserved: (Patient, Provider, None). null (Strength=Example) Funds Reservation FundsReservationCodes ?? » A code for the form to be used for printing the content formCode : CodeableConcept [0..1] « The forms codes. null (Strength=Example) Form FormCodes ?? » The actual form, by reference or inclusion, for printing the content or an EOB form : Attachment [0..1] Request for additional supporting or authorizing information communicationRequest : Reference [0..*] « CommunicationRequest » Event A coded event such as when a service is expected or a card printed type : CodeableConcept [1..1] « null (Strength=Example) DatesTypeCodes ?? » A date or period in the past or future indicating when the event occurred or is expectd to occur when[x] : DataType [1..1] « dateTime | Period » Item A number to uniquely reference the claim item entries itemSequence : positiveInt [1..1] Trace number for tracking purposes. May be defined at the jurisdiction level or between trading partners traceNumber : Identifier [0..*] The numbers associated with notes below which apply to the adjudication of this item noteNumber : positiveInt [0..*] ReviewOutcome The result of the claim, predetermination, or preauthorization adjudication decision : CodeableConcept [0..1] « null (Strength=Example) ClaimAdjudicationDecisionsCod... ?? » The reasons for the result of the claim, predetermination, or preauthorization adjudication reason : CodeableConcept [0..*] « null (Strength=Example) ClaimAdjudicationDecisionReas... ?? » Reference from the Insurer which is used in later communications which refers to this adjudication preAuthRef : string [0..1] The time frame during which this authorization is effective preAuthPeriod : Period [0..1] Adjudication 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 category : CodeableConcept [1..1] « The adjudication codes. null (Strength=Example) AdjudicationValueCodes ?? » A code supporting the understanding of the adjudication result and explaining variance from expected amount reason : CodeableConcept [0..1] « The adjudication reason codes. null (Strength=Example) AdjudicationReasonCodes ?? » Monetary amount associated with the category amount : Money [0..1] A non-monetary value associated with the category. Mutually exclusive to the amount element above value quantity : decimal Quantity [0..1] ItemDetail A number to uniquely reference the claim detail entry detailSequence : positiveInt [1..1] Trace number for tracking purposes. May be defined at the jurisdiction level or between trading partners traceNumber : Identifier [0..*] The numbers associated with notes below which apply to the adjudication of this item noteNumber : positiveInt [0..*] SubDetail A number to uniquely reference the claim sub-detail entry subDetailSequence : positiveInt [1..1] Trace number for tracking purposes. May be defined at the jurisdiction level or between trading partners traceNumber : Identifier [0..*] The numbers associated with notes below which apply to the adjudication of this item noteNumber : positiveInt [0..*] AddedItem Claim items which this service line is intended to replace itemSequence : positiveInt [0..*] The sequence number of the details within the claim item which this line is intended to replace detailSequence : positiveInt [0..*] The sequence number of the sub-details within the details within the claim item which this line is intended to replace subdetailSequence : positiveInt [0..*] Trace number for tracking purposes. May be defined at the jurisdiction level or between trading partners traceNumber : Identifier [0..*] The providers who are authorized for the services rendered to the patient provider : Reference [0..*] « Practitioner | PractitionerRole | Organization » The type of revenue or cost center providing the product and/or service revenue : CodeableConcept [0..1] « null (Strength=Example) ExampleRevenueCenterCodes ?? » When the value is a group code then this item collects a set of related claim item details, otherwise this contains the product, service, drug or other billing code for the item item. This element may be the start of a range of .productOrService codes used in conjunction with .productOrServiceEnd or it may be a solo element where .productOrServiceEnd is not used productOrService : CodeableConcept [1..1] [0..1] « Allowable service null (Strength=Example) USCLSCodes ?? » This contains the end of a range of product, service, drug or other billing codes for the item. This element is not used when the .productOrService is a group code. This value may only be present when a .productOfService code has been provided to convey the start of the range. Typically this value may be used only with preauthorizations and product codes. not with claims productOrServiceEnd : CodeableConcept [0..1] « null (Strength=Example) USCLSCodes ?? » Request or Referral for Goods or Service to be rendered request : Reference [0..*] « DeviceRequest | MedicationRequest | NutritionOrder | ServiceRequest | SupplyRequest | VisionPrescription » Item typification or modifiers codes to convey additional context for the product or service modifier : CodeableConcept [0..*] « Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen. null (Strength=Example) ModifierTypeCodes ?? » Identifies the program under which this may be recovered programCode : CodeableConcept [0..*] « Program specific reason codes. null (Strength=Example) ExampleProgramReasonCodes ?? » The date or dates when the service or product was supplied, performed or completed serviced[x] : Type DataType [0..1] « date | Period » Where the product or service was provided location[x] : Type DataType [0..1] « CodeableConcept | Address | Reference ( Location ); Place of service: pharmacy, school, prison, etc. null (Strength=Example) ExampleServicePlaceCodes ?? » The number of repetitions of a service or product quantity : Quantity ( SimpleQuantity ) [0..1] 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 unitPrice : Money [0..1] A real number that represents a multiplier used in determining the overall value of services delivered and/or goods received. The concept of a Factor allows for a discount or surcharge multiplier to be applied to a monetary amount factor : decimal [0..1] The quantity times the unit price total of taxes applicable for an additional service or this product or charge service tax : Money [0..1] The total amount claimed for the group (if a grouper) or the addItem. Net = unit price * quantity * factor net : Money [0..1] The numbers associated with notes below which apply to the adjudication of this item noteNumber : positiveInt [0..*] BodySite Physical service site on the patient (limb, tooth, etc.) bodySite site : CodeableConcept CodeableReference [0..1] [1..*] « BodyStructure ; The code for the teeth, quadrant, sextant and arch. null (Strength=Example) OralSiteCodes ?? » A region or surface of the bodySite, e.g. limb region or tooth surface(s) subSite : CodeableConcept [0..*] « The code for the tooth surface and surface combinations. null (Strength=Example) SurfaceCodes ?? » AddedItemDetail The numbers associated with notes below which apply to Trace number for tracking purposes. May be defined at the adjudication of this item jurisdiction level or between trading partners noteNumber traceNumber : positiveInt Identifier [0..*] The type of revenue or cost center providing the product and/or service revenue : CodeableConcept [0..1] « AddedItemDetail null (Strength=Example) ExampleRevenueCenterCodes ?? » When the value is a group code then this item collects a set of related claim item details, otherwise this contains the product, service, drug or other billing code for the item item. This element may be the start of a range of .productOrService codes used in conjunction with .productOrServiceEnd or it may be a solo element where .productOrServiceEnd is not used productOrService : CodeableConcept [1..1] [0..1] « Allowable service null (Strength=Example) USCLSCodes ?? » This contains the end of a range of product, service, drug or other billing codes for the item. This element is not used when the .productOrService is a group code. This value may only be present when a .productOfService code has been provided to convey the start of the range. Typically this value may be used only with preauthorizations and product codes. not with claims productOrServiceEnd : CodeableConcept [0..1] « null (Strength=Example) USCLSCodes ?? » Item typification or modifiers codes to convey additional context for the product or service modifier : CodeableConcept [0..*] « Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen. null (Strength=Example) ModifierTypeCodes ?? » The number of repetitions of a service or product quantity : Quantity ( SimpleQuantity ) [0..1] 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 unitPrice : Money [0..1] A real number that represents a multiplier used in determining the overall value of services delivered and/or goods received. The concept of a Factor allows for a discount or surcharge multiplier to be applied to a monetary amount factor : decimal [0..1] The quantity times the unit price total of taxes applicable for an additional service or this product or charge service tax : Money [0..1] The total amount claimed for the group (if a grouper) or the addItem.detail. Net = unit price * quantity * factor net : Money [0..1] The numbers associated with notes below which apply to the adjudication of this item noteNumber : positiveInt [0..*] AddedItemSubDetail AddedItemSubDetail Trace number for tracking purposes. May be defined at the jurisdiction level or between trading partners traceNumber : Identifier [0..*] The type of revenue or cost center providing the product and/or service revenue : CodeableConcept [0..1] « null (Strength=Example) ExampleRevenueCenterCodes ?? » When the value is a group code then this item collects a set of related claim item details, otherwise this contains the product, service, drug or other billing code for the item item. This element may be the start of a range of .productOrService codes used in conjunction with .productOrServiceEnd or it may be a solo element where .productOrServiceEnd is not used productOrService : CodeableConcept [1..1] [0..1] « Allowable service null (Strength=Example) USCLSCodes ?? » This contains the end of a range of product, service, drug or other billing codes for the item. This element is not used when the .productOrService is a group code. This value may only be present when a .productOfService code has been provided to convey the start of the range. Typically this value may be used only with preauthorizations and product codes. not with claims productOrServiceEnd : CodeableConcept [0..1] « null (Strength=Example) USCLSCodes ?? » Item typification or modifiers codes to convey additional context for the product or service modifier : CodeableConcept [0..*] « Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen. null (Strength=Example) ModifierTypeCodes ?? » The number of repetitions of a service or product quantity : Quantity ( SimpleQuantity ) [0..1] 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 unitPrice : Money [0..1] A real number that represents a multiplier used in determining the overall value of services delivered and/or goods received. The concept of a Factor allows for a discount or surcharge multiplier to be applied to a monetary amount factor : decimal [0..1] The quantity times the unit price total of taxes applicable for an additional service or this product or charge service tax : Money [0..1] The total amount claimed for the addItem.detail.subDetail. Net = unit price * quantity * factor net : Money [0..1] The numbers associated with notes below which apply to the adjudication of this item noteNumber : positiveInt [0..*] Total 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 category : CodeableConcept [1..1] « The adjudication codes. null (Strength=Example) AdjudicationValueCodes ?? » Monetary total amount associated with the category amount : Money [1..1] Payment Whether this represents partial or complete payment of the benefits payable type : CodeableConcept [1..1] « The type (partial, complete) of the payment. null (Strength=Example) ExamplePaymentTypeCodes ?? » Total amount of all adjustments to this payment included in this transaction which are not related to this claim's adjudication adjustment : Money [0..1] Reason for the payment adjustment adjustmentReason : CodeableConcept [0..1] « Payment Adjustment reason codes. null (Strength=Example) PaymentAdjustmentReasonCodes ?? » Estimated date the payment will be issued or the actual issue date of payment date : date [0..1] Benefits payable less any payment adjustment amount : Money [1..1] Issuer's unique identifier for the payment instrument identifier : Identifier [0..1] Note A number to uniquely identify a note entry number : positiveInt [0..1] The business purpose of the note text type : code CodeableConcept [0..1] « The presentation types of notes. (Strength=Required) null (Strength=Extensible) NoteType ! + » The explanation or description associated with the processing text : string [1..1] A code to define the language used in the text of the note language : CodeableConcept [0..1] « A human language. (Strength=Preferred) null (Strength=Required) CommonLanguages ? AllLanguages ! » Insurance A number to uniquely identify insurance entries and provide a sequence of coverages to convey coordination of benefit order sequence : positiveInt [1..1] A flag to indicate that this Coverage is to be used for adjudication of this claim when set to true focal : boolean [1..1] Reference to the 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 coverage : Reference [1..1] « Coverage » A business agreement number established between the provider and the insurer for special business processing purposes businessArrangement : string [0..1] The result of the adjudication of the line items for the Coverage specified in this insurance claimResponse : Reference [0..1] « ClaimResponse » Error The sequence number of the line item submitted which contains the error. This value is omitted when the error occurs outside of the item structure itemSequence : positiveInt [0..1] The 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 detailSequence : positiveInt [0..1] 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 subDetailSequence : positiveInt [0..1] An error code, from a specified code system, which details why the claim could not be adjudicated code : CodeableConcept [1..1] « The adjudication error codes. null (Strength=Example) Adjudication Error AdjudicationErrorCodes ?? » A [simple subset of FHIRPath](fhirpath.html#simple) limited to element names, repetition indicators and the default child accessor that identifies one of the elements in the resource that caused this issue to be raised expression : string [0..*] Information code for an event with a corresponding date or period event [0..*] The high-level results of the adjudication if adjudication has been performed reviewOutcome [0..1] If this item is a group then the values here are a summary of the adjudication of the detail items. If this item is a simple product or service then this is the result of the adjudication of this item adjudication [1..*] [0..*] The high-level results of the adjudication if adjudication has been performed reviewOutcome [0..1] The adjudication results adjudication [1..*] [0..*] The high-level results of the adjudication if adjudication has been performed reviewOutcome [0..1] The adjudication results adjudication [0..*] A sub-detail adjudication of a simple product or service subDetail [0..*] A claim detail. Either a simple (a product or service) or a 'group' of sub-details which are simple items detail [0..*] 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 item [0..*] Physical location where the service is performed or applies bodySite [0..*] The high-level results of the adjudication if adjudication has been performed reviewOutcome [0..1] The adjudication results adjudication [1..*] [0..*] The high-level results of the adjudication if adjudication has been performed reviewOutcome [0..1] The adjudication results adjudication [1..*] [0..*] The high-level results of the adjudication if adjudication has been performed reviewOutcome [0..1] The adjudication results adjudication [1..*] [0..*] The third-tier service adjudications for payor added services subDetail [0..*] The second-tier service adjudications for payor added services detail [0..*] The first-tier service adjudications for payor added product or service lines addItem [0..*] The adjudication results which are presented at the header level rather than at the line-item or add-item levels adjudication [0..*] Categorized monetary totals for the adjudication total [0..*] Payment details for the adjudication of the claim payment [0..1] A note that describes or explains adjudication results in a human readable form processNote [0..*] Financial instruments for reimbursement for the health care products and services specified on the claim insurance [0..*] Errors encountered during the processing of the adjudication error [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 Business Identifier for a claim response --></identifier>
 <traceNumber><!-- 0..* Identifier Number for tracking --></traceNumber>

 <status value="[code]"/><!-- 1..1 active | cancelled | draft | entered-in-error -->
 <type><!-- 1..1 CodeableConcept More granular claim type --></type>
 <subType><!-- 0..1 CodeableConcept More granular claim type --></subType>
 <

 <use value="[code]"/><!-- 1..1 claim | preauthorization | predetermination -->

 <patient><!-- 1..1 Reference(Patient) The recipient of the products and services --></patient>
 <created value="[dateTime]"/><!-- 1..1 Response creation date -->
 <</insurer>
 <</requestor>

 <insurer><!-- 0..1 Reference(Organization) Party responsible for reimbursement --></insurer>
 <requestor><!-- 0..1 Reference(Organization|Practitioner|PractitionerRole) Party responsible for the claim --></requestor>

 <request><!-- 0..1 Reference(Claim) Id of resource triggering adjudication --></request>
 <

 <outcome value="[code]"/><!-- 1..1 queued | complete | error | partial -->
 <decision><!-- 0..1 CodeableConcept Result of the adjudication --></decision>

 <disposition value="[string]"/><!-- 0..1 Disposition Message -->
 <preAuthRef value="[string]"/><!-- 0..1 Preauthorization reference -->
 <preAuthPeriod><!-- 0..1 Period Preauthorization reference effective period --></preAuthPeriod>
 <event>  <!-- 0..* Event information -->
  <type><!-- 1..1 CodeableConcept Specific event --></type>
  <when[x]><!-- 1..1 dateTime|Period Occurance date or period --></when[x]>
 </event>

 <payeeType><!-- 0..1 CodeableConcept Party to be paid any benefits payable --></payeeType>
 <encounter><!-- 0..* Reference(Encounter) Encounters associated with the listed treatments --></encounter>
 <diagnosisRelatedGroup><!-- 0..1 CodeableConcept Package billing code --></diagnosisRelatedGroup>

 <item>  <!-- 0..* Adjudication for claim line items -->
  <itemSequence value="[positiveInt]"/><!-- 1..1 Claim item instance identifier -->
  <traceNumber><!-- 0..* Identifier Number for tracking --></traceNumber>

  <noteNumber value="[positiveInt]"/><!-- 0..* Applicable note numbers -->
  <

  <reviewOutcome>  <!-- 0..1 Adjudication results -->
   <decision><!-- 0..1 CodeableConcept Result of the adjudication --></decision>
   <reason><!-- 0..* CodeableConcept Reason for result of the adjudication --></reason>
   <preAuthRef value="[string]"/><!-- 0..1 Preauthorization reference -->
   <preAuthPeriod><!-- 0..1 Period Preauthorization reference effective period --></preAuthPeriod>
  </reviewOutcome>
  <adjudication>  <!-- 0..* Adjudication details -->

   <category><!-- 1..1 CodeableConcept Type of adjudication information --></category>
   <reason><!-- 0..1 CodeableConcept Explanation of adjudication outcome --></reason>
   <amount><!-- 0..1 Money Monetary amount --></amount>
   <

   <quantity><!-- 0..1 Quantity Non-monetary value --></quantity>

  </adjudication>
  <detail>  <!-- 0..* Adjudication for claim details -->
   <detailSequence value="[positiveInt]"/><!-- 1..1 Claim detail instance identifier -->
   <traceNumber><!-- 0..* Identifier Number for tracking --></traceNumber>

   <noteNumber value="[positiveInt]"/><!-- 0..* Applicable note numbers -->
   <</adjudication>

   <reviewOutcome><!-- 0..1 Content as for ClaimResponse.item.reviewOutcome Detail level adjudication results --></reviewOutcome>
   <adjudication><!-- 0..* Content as for ClaimResponse.item.adjudication Detail level adjudication details --></adjudication>

   <subDetail>  <!-- 0..* Adjudication for claim sub-details -->
    <subDetailSequence value="[positiveInt]"/><!-- 1..1 Claim sub-detail instance identifier -->
    <traceNumber><!-- 0..* Identifier Number for tracking --></traceNumber>

    <noteNumber value="[positiveInt]"/><!-- 0..* Applicable note numbers -->
    <reviewOutcome><!-- 0..1 Content as for ClaimResponse.item.reviewOutcome Subdetail level adjudication results --></reviewOutcome>

    <adjudication><!-- 0..* Content as for ClaimResponse.item.adjudication Subdetail level adjudication details --></adjudication>
   </subDetail>
  </detail>
 </item>
 <addItem>  <!-- 0..* Insurer added line items -->
  <itemSequence value="[positiveInt]"/><!-- 0..* Item sequence number -->
  <detailSequence value="[positiveInt]"/><!-- 0..* Detail sequence number -->
  <subdetailSequence value="[positiveInt]"/><!-- 0..* Subdetail sequence number -->
  <</provider>
  <</productOrService>

  <traceNumber><!-- 0..* Identifier Number for tracking --></traceNumber>
  <provider><!-- 0..* Reference(Organization|Practitioner|PractitionerRole) Authorized providers --></provider>
  <revenue><!-- 0..1 CodeableConcept Revenue or cost center code --></revenue>
  <productOrService><!-- 0..1 CodeableConcept Billing, service, product, or drug code --></productOrService>
  <productOrServiceEnd><!-- 0..1 CodeableConcept End of a range of codes --></productOrServiceEnd>
  <request><!-- 0..* Reference(DeviceRequest|MedicationRequest|NutritionOrder|
    ServiceRequest|SupplyRequest|VisionPrescription) Request or Referral for Service --></request>
  <modifier><!-- 0..* CodeableConcept Service/Product billing modifiers --></modifier>
  <programCode><!-- 0..* CodeableConcept Program the product or service is provided under --></programCode>
  <serviced[x]><!-- 0..1 date|Period Date or dates of service or product delivery --></serviced[x]>
  <location[x]><!-- 0..1 CodeableConcept|Address|Reference(Location) Place of service or where product was supplied --></location[x]>
  <quantity><!-- 0..1 Quantity(SimpleQuantity) Count of products or services --></quantity>
  <unitPrice><!-- 0..1 Money Fee, charge or cost per item --></unitPrice>
  <factor value="[decimal]"/><!-- 0..1 Price scaling factor -->
  <</net>
  <</bodySite>
  <</subSite>

  <tax><!-- 0..1 Money Total tax --></tax>
  <net><!-- 0..1 Money Total item cost --></net>
  <bodySite>  <!-- 0..* Anatomical location -->
   <site><!-- 1..* CodeableReference(BodyStructure) Location --></site>
   <subSite><!-- 0..* CodeableConcept Sub-location --></subSite>
  </bodySite>

  <noteNumber value="[positiveInt]"/><!-- 0..* Applicable note numbers -->
  <</adjudication>

  <reviewOutcome><!-- 0..1 Content as for ClaimResponse.item.reviewOutcome Added items adjudication results --></reviewOutcome>
  <adjudication><!-- 0..* Content as for ClaimResponse.item.adjudication Added items adjudication --></adjudication>

  <detail>  <!-- 0..* Insurer added line details -->
   <</productOrService>

   <traceNumber><!-- 0..* Identifier Number for tracking --></traceNumber>
   <revenue><!-- 0..1 CodeableConcept Revenue or cost center code --></revenue>
   <productOrService><!-- 0..1 CodeableConcept Billing, service, product, or drug code --></productOrService>
   <productOrServiceEnd><!-- 0..1 CodeableConcept End of a range of codes --></productOrServiceEnd>

   <modifier><!-- 0..* CodeableConcept Service/Product billing modifiers --></modifier>
   <quantity><!-- 0..1 Quantity(SimpleQuantity) Count of products or services --></quantity>
   <unitPrice><!-- 0..1 Money Fee, charge or cost per item --></unitPrice>
   <factor value="[decimal]"/><!-- 0..1 Price scaling factor -->
   <</net>

   <tax><!-- 0..1 Money Total tax --></tax>
   <net><!-- 0..1 Money Total item cost --></net>

   <noteNumber value="[positiveInt]"/><!-- 0..* Applicable note numbers -->
   <</adjudication>

   <reviewOutcome><!-- 0..1 Content as for ClaimResponse.item.reviewOutcome Added items detail level adjudication results --></reviewOutcome>
   <adjudication><!-- 0..* Content as for ClaimResponse.item.adjudication Added items detail adjudication --></adjudication>

   <subDetail>  <!-- 0..* Insurer added line items -->
    <</productOrService>

    <traceNumber><!-- 0..* Identifier Number for tracking --></traceNumber>
    <revenue><!-- 0..1 CodeableConcept Revenue or cost center code --></revenue>
    <productOrService><!-- 0..1 CodeableConcept Billing, service, product, or drug code --></productOrService>
    <productOrServiceEnd><!-- 0..1 CodeableConcept End of a range of codes --></productOrServiceEnd>

    <modifier><!-- 0..* CodeableConcept Service/Product billing modifiers --></modifier>
    <quantity><!-- 0..1 Quantity(SimpleQuantity) Count of products or services --></quantity>
    <unitPrice><!-- 0..1 Money Fee, charge or cost per item --></unitPrice>
    <factor value="[decimal]"/><!-- 0..1 Price scaling factor -->
    <</net>

    <tax><!-- 0..1 Money Total tax --></tax>
    <net><!-- 0..1 Money Total item cost --></net>

    <noteNumber value="[positiveInt]"/><!-- 0..* Applicable note numbers -->
    <</adjudication>

    <reviewOutcome><!-- 0..1 Content as for ClaimResponse.item.reviewOutcome Added items subdetail level adjudication results --></reviewOutcome>
    <adjudication><!-- 0..* Content as for ClaimResponse.item.adjudication Added items subdetail adjudication --></adjudication>

   </subDetail>
  </detail>
 </addItem>
 <adjudication><!-- 0..* Content as for ClaimResponse.item.adjudication Header-level adjudication --></adjudication>
 <total>  <!-- 0..* Adjudication totals -->
  <category><!-- 1..1 CodeableConcept Type of adjudication information --></category>
  <amount><!-- 1..1 Money Financial total for the category --></amount>
 </total>
 <payment>  <!-- 0..1 Payment Details -->
  <type><!-- 1..1 CodeableConcept Partial or complete payment --></type>
  <adjustment><!-- 0..1 Money Payment adjustment for non-claim issues --></adjustment>
  <adjustmentReason><!-- 0..1 CodeableConcept Explanation for the adjustment --></adjustmentReason>
  <date value="[date]"/><!-- 0..1 Expected date of payment -->
  <amount><!-- 1..1 Money Payable amount after adjustment --></amount>
  <identifier><!-- 0..1 Identifier Business identifier for the payment --></identifier>
 </payment>
 <fundsReserve><!-- 0..1 CodeableConcept Funds reserved status --></fundsReserve>
 <formCode><!-- 0..1 CodeableConcept Printed form identifier --></formCode>
 <form><!-- 0..1 Attachment Printed reference or actual form --></form>
 <processNote>  <!-- 0..* Note concerning adjudication -->
  <number value="[positiveInt]"/><!-- 0..1 Note instance identifier -->
  <

  <type><!-- 0..1 CodeableConcept Note purpose --></type>

  <text value="[string]"/><!-- 1..1 Note explanatory text -->
  <</language>

  <language><!-- 0..1 CodeableConcept Language of the text --></language>

 </processNote>
 <communicationRequest><!-- 0..* Reference(CommunicationRequest) Request for additional information --></communicationRequest>
 <insurance>  <!-- 0..* Patient insurance information -->
  <sequence value="[positiveInt]"/><!-- 1..1 Insurance instance identifier -->
  <focal value="[boolean]"/><!-- 1..1 Coverage to be used for adjudication -->
  <coverage><!-- 1..1 Reference(Coverage) Insurance information --></coverage>
  <businessArrangement value="[string]"/><!-- 0..1 Additional provider contract number -->
  <claimResponse><!-- 0..1 Reference(ClaimResponse) Adjudication results --></claimResponse>
 </insurance>
 <error>  <!-- 0..* Processing errors -->
  <itemSequence value="[positiveInt]"/><!-- 0..1 Item sequence number -->
  <detailSequence value="[positiveInt]"/><!-- 0..1 Detail sequence number -->
  <subDetailSequence value="[positiveInt]"/><!-- 0..1 Subdetail sequence number -->
  <code><!-- 1..1 CodeableConcept Error code detailing processing issues --></code>
  <expression value="[string]"/><!-- 0..* FHIRPath of element(s) related to issue -->

 </error>
</ClaimResponse>

JSON Template 

{doco
  "resourceType" : "ClaimResponse",
  // from Resource: id, meta, implicitRules, and language
  // from DomainResource: text, contained, extension, and modifierExtension
  "identifier" : [{ Identifier }], // Business Identifier for a claim response
  "traceNumber" : [{ Identifier }], // Number for tracking

  "status" : "<code>", // R!  active | cancelled | draft | entered-in-error
  "type" : { CodeableConcept }, // R!  More granular claim type
  "subType" : { CodeableConcept }, // More granular claim type
  "

  "use" : "<code>", // R!  claim | preauthorization | predetermination

  "patient" : { Reference(Patient) }, // R!  The recipient of the products and services
  "created" : "<dateTime>", // R!  Response creation date
  "
  "

  "insurer" : { Reference(Organization) }, // Party responsible for reimbursement
  "requestor" : { Reference(Organization|Practitioner|PractitionerRole) }, // Party responsible for the claim

  "request" : { Reference(Claim) }, // Id of resource triggering adjudication
  "

  "outcome" : "<code>", // R!  queued | complete | error | partial
  "decision" : { CodeableConcept }, // Result of the adjudication

  "disposition" : "<string>", // Disposition Message
  "preAuthRef" : "<string>", // Preauthorization reference
  "preAuthPeriod" : { Period }, // Preauthorization reference effective period
  "event" : [{ // Event information
    "type" : { CodeableConcept }, // R!  Specific event
    // when[x]: Occurance date or period. One of these 2:

    "whenDateTime" : "<dateTime>",
    "whenPeriod" : { Period }
  }],

  "payeeType" : { CodeableConcept }, // Party to be paid any benefits payable
  "encounter" : [{ Reference(Encounter) }], // Encounters associated with the listed treatments
  "diagnosisRelatedGroup" : { CodeableConcept }, // Package billing code

  "item" : [{ // Adjudication for claim line items
    "itemSequence" : "<positiveInt>", // R!  Claim item instance identifier
    "traceNumber" : [{ Identifier }], // Number for tracking

    "noteNumber" : ["<positiveInt>"], // Applicable note numbers
    "

    "reviewOutcome" : { // Adjudication results
      "decision" : { CodeableConcept }, // Result of the adjudication
      "reason" : [{ CodeableConcept }], // Reason for result of the adjudication
      "preAuthRef" : "<string>", // Preauthorization reference
      "preAuthPeriod" : { Period } // Preauthorization reference effective period
    },
    "adjudication" : [{ // Adjudication details

      "category" : { CodeableConcept }, // R!  Type of adjudication information
      "reason" : { CodeableConcept }, // Explanation of adjudication outcome
      "amount" : { Money }, // Monetary amount
      "

      "quantity" : { Quantity } // Non-monetary value

    }],
    "detail" : [{ // Adjudication for claim details
      "detailSequence" : "<positiveInt>", // R!  Claim detail instance identifier
      "traceNumber" : [{ Identifier }], // Number for tracking

      "noteNumber" : ["<positiveInt>"], // Applicable note numbers
      "

      "reviewOutcome" : { Content as for ClaimResponse.item.reviewOutcome }, // Detail level adjudication results
      "adjudication" : [{ Content as for ClaimResponse.item.adjudication }], // Detail level adjudication details

      "subDetail" : [{ // Adjudication for claim sub-details
        "subDetailSequence" : "<positiveInt>", // R!  Claim sub-detail instance identifier
        "traceNumber" : [{ Identifier }], // Number for tracking

        "noteNumber" : ["<positiveInt>"], // Applicable note numbers
        "reviewOutcome" : { Content as for ClaimResponse.item.reviewOutcome }, // Subdetail level adjudication results

        "adjudication" : [{ Content as for ClaimResponse.item.adjudication }] // Subdetail level adjudication details
      }]
    }]
  }],
  "addItem" : [{ // Insurer added line items
    "itemSequence" : ["<positiveInt>"], // Item sequence number
    "detailSequence" : ["<positiveInt>"], // Detail sequence number
    "subdetailSequence" : ["<positiveInt>"], // Subdetail sequence number
    "
    "

    "traceNumber" : [{ Identifier }], // Number for tracking
    "provider" : [{ Reference(Organization|Practitioner|PractitionerRole) }], // Authorized providers
    "revenue" : { CodeableConcept }, // Revenue or cost center code
    "productOrService" : { CodeableConcept }, // Billing, service, product, or drug code
    "productOrServiceEnd" : { CodeableConcept }, // End of a range of codes
    "request" : [{ Reference(DeviceRequest|MedicationRequest|NutritionOrder|
    ServiceRequest|SupplyRequest|VisionPrescription) }], // Request or Referral for Service
    "modifier" : [{ CodeableConcept }], // Service/Product billing modifiers
    "programCode" : [{ CodeableConcept }], // Program the product or service is provided under
    // serviced[x]: Date or dates of service or product delivery. One of these 2:
    "servicedDate" : "<date>",
    "servicedPeriod" : { Period },
    // location[x]: Place of service or where product was supplied. One of these 3:
    "locationCodeableConcept" : { CodeableConcept },
    "locationAddress" : { Address },
    "locationReference" : { Reference(Location) },
    "quantity" : { Quantity(SimpleQuantity) }, // Count of products or services
    "unitPrice" : { Money }, // Fee, charge or cost per item
    "factor" : <decimal>, // Price scaling factor
    "
    "
    "

    "tax" : { Money }, // Total tax
    "net" : { Money }, // Total item cost
    "bodySite" : [{ // Anatomical location
      "site" : [{ CodeableReference(BodyStructure) }], // R!  Location
      "subSite" : [{ CodeableConcept }] // Sub-location
    }],

    "noteNumber" : ["<positiveInt>"], // Applicable note numbers
    "

    "reviewOutcome" : { Content as for ClaimResponse.item.reviewOutcome }, // Added items adjudication results
    "adjudication" : [{ Content as for ClaimResponse.item.adjudication }], // Added items adjudication

    "detail" : [{ // Insurer added line details
      "

      "traceNumber" : [{ Identifier }], // Number for tracking
      "revenue" : { CodeableConcept }, // Revenue or cost center code
      "productOrService" : { CodeableConcept }, // Billing, service, product, or drug code
      "productOrServiceEnd" : { CodeableConcept }, // End of a range of codes

      "modifier" : [{ CodeableConcept }], // Service/Product billing modifiers
      "quantity" : { Quantity(SimpleQuantity) }, // Count of products or services
      "unitPrice" : { Money }, // Fee, charge or cost per item
      "factor" : <decimal>, // Price scaling factor
      "

      "tax" : { Money }, // Total tax
      "net" : { Money }, // Total item cost

      "noteNumber" : ["<positiveInt>"], // Applicable note numbers
      "

      "reviewOutcome" : { Content as for ClaimResponse.item.reviewOutcome }, // Added items detail level adjudication results
      "adjudication" : [{ Content as for ClaimResponse.item.adjudication }], // Added items detail adjudication

      "subDetail" : [{ // Insurer added line items
        "

        "traceNumber" : [{ Identifier }], // Number for tracking
        "revenue" : { CodeableConcept }, // Revenue or cost center code
        "productOrService" : { CodeableConcept }, // Billing, service, product, or drug code
        "productOrServiceEnd" : { CodeableConcept }, // End of a range of codes

        "modifier" : [{ CodeableConcept }], // Service/Product billing modifiers
        "quantity" : { Quantity(SimpleQuantity) }, // Count of products or services
        "unitPrice" : { Money }, // Fee, charge or cost per item
        "factor" : <decimal>, // Price scaling factor
        "

        "tax" : { Money }, // Total tax
        "net" : { Money }, // Total item cost

        "noteNumber" : ["<positiveInt>"], // Applicable note numbers
        "

        "reviewOutcome" : { Content as for ClaimResponse.item.reviewOutcome }, // Added items subdetail level adjudication results
        "adjudication" : [{ Content as for ClaimResponse.item.adjudication }] // Added items subdetail adjudication

      }]
    }]
  }],
  "adjudication" : [{ Content as for ClaimResponse.item.adjudication }], // Header-level adjudication
  "total" : [{ // Adjudication totals
    "category" : { CodeableConcept }, // R!  Type of adjudication information
    "amount" : { Money } // R!  Financial total for the category
  }],
  "payment" : { // Payment Details
    "type" : { CodeableConcept }, // R!  Partial or complete payment
    "adjustment" : { Money }, // Payment adjustment for non-claim issues
    "adjustmentReason" : { CodeableConcept }, // Explanation for the adjustment
    "date" : "<date>", // Expected date of payment
    "amount" : { Money }, // R!  Payable amount after adjustment
    "identifier" : { Identifier } // Business identifier for the payment
  },
  "fundsReserve" : { CodeableConcept }, // Funds reserved status
  "formCode" : { CodeableConcept }, // Printed form identifier
  "form" : { Attachment }, // Printed reference or actual form
  "processNote" : [{ // Note concerning adjudication
    "number" : "<positiveInt>", // Note instance identifier
    "

    "type" : { CodeableConcept }, // Note purpose

    "text" : "<string>", // R!  Note explanatory text
    "

    "language" : { CodeableConcept } // Language of the text

  }],
  "communicationRequest" : [{ Reference(CommunicationRequest) }], // Request for additional information
  "insurance" : [{ // Patient insurance information
    "sequence" : "<positiveInt>", // R!  Insurance instance identifier
    "focal" : <boolean>, // R!  Coverage to be used for adjudication
    "coverage" : { Reference(Coverage) }, // R!  Insurance information
    "businessArrangement" : "<string>", // Additional provider contract number
    "claimResponse" : { Reference(ClaimResponse) } // Adjudication results
  }],
  "error" : [{ // Processing errors
    "itemSequence" : "<positiveInt>", // Item sequence number
    "detailSequence" : "<positiveInt>", // Detail sequence number
    "subDetailSequence" : "<positiveInt>", // Subdetail sequence number
    "

    "code" : { CodeableConcept }, // R!  Error code detailing processing issues
    "expression" : ["<string>"] // FHIRPath of element(s) related to issue

  }]
}

Turtle Template 

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


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

  # from Resource: .id, .meta, .implicitRules, and .language
  # from DomainResource: .text, .contained, .extension, and .modifierExtension
  fhir:
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    # . One of these 2
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    # . One of these 3
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  ], ...;

  fhir:identifier  ( [ Identifier ] ... ) ; # 0..* Business Identifier for a claim response
  fhir:traceNumber  ( [ Identifier ] ... ) ; # 0..* Number for tracking
  fhir:status [ code ] ; # 1..1 active | cancelled | draft | entered-in-error
  fhir:type [ CodeableConcept ] ; # 1..1 More granular claim type
  fhir:subType [ CodeableConcept ] ; # 0..1 More granular claim type
  fhir:use [ code ] ; # 1..1 claim | preauthorization | predetermination
  fhir:patient [ Reference(Patient) ] ; # 1..1 The recipient of the products and services
  fhir:created [ dateTime ] ; # 1..1 Response creation date
  fhir:insurer [ Reference(Organization) ] ; # 0..1 Party responsible for reimbursement
  fhir:requestor [ Reference(Organization|Practitioner|PractitionerRole) ] ; # 0..1 Party responsible for the claim
  fhir:request [ Reference(Claim) ] ; # 0..1 Id of resource triggering adjudication
  fhir:outcome [ code ] ; # 1..1 queued | complete | error | partial
  fhir:decision [ CodeableConcept ] ; # 0..1 Result of the adjudication
  fhir:disposition [ string ] ; # 0..1 Disposition Message
  fhir:preAuthRef [ string ] ; # 0..1 Preauthorization reference
  fhir:preAuthPeriod [ Period ] ; # 0..1 Preauthorization reference effective period
  fhir:event ( [ # 0..* Event information
    fhir:type [ CodeableConcept ] ; # 1..1 Specific event
    # when[x] : 1..1 Occurance date or period. One of these 2
      fhir:when [  a fhir:dateTime ; dateTime ]
      fhir:when [  a fhir:Period ; Period ]
  ] ... ) ;
  fhir:payeeType [ CodeableConcept ] ; # 0..1 Party to be paid any benefits payable
  fhir:encounter  ( [ Reference(Encounter) ] ... ) ; # 0..* Encounters associated with the listed treatments
  fhir:diagnosisRelatedGroup [ CodeableConcept ] ; # 0..1 Package billing code
  fhir:item ( [ # 0..* Adjudication for claim line items
    fhir:itemSequence [ positiveInt ] ; # 1..1 Claim item instance identifier
    fhir:traceNumber  ( [ Identifier ] ... ) ; # 0..* Number for tracking
    fhir:noteNumber  ( [ positiveInt ] ... ) ; # 0..* Applicable note numbers
    fhir:reviewOutcome [ # 0..1 Adjudication results
      fhir:decision [ CodeableConcept ] ; # 0..1 Result of the adjudication
      fhir:reason  ( [ CodeableConcept ] ... ) ; # 0..* Reason for result of the adjudication
      fhir:preAuthRef [ string ] ; # 0..1 Preauthorization reference
      fhir:preAuthPeriod [ Period ] ; # 0..1 Preauthorization reference effective period
    ] ;
    fhir:adjudication ( [ # 0..* Adjudication details
      fhir:category [ CodeableConcept ] ; # 1..1 Type of adjudication information
      fhir:reason [ CodeableConcept ] ; # 0..1 Explanation of adjudication outcome
      fhir:amount [ Money ] ; # 0..1 Monetary amount
      fhir:quantity [ Quantity ] ; # 0..1 Non-monetary value
    ] ... ) ;
    fhir:detail ( [ # 0..* Adjudication for claim details
      fhir:detailSequence [ positiveInt ] ; # 1..1 Claim detail instance identifier
      fhir:traceNumber  ( [ Identifier ] ... ) ; # 0..* Number for tracking
      fhir:noteNumber  ( [ positiveInt ] ... ) ; # 0..* Applicable note numbers
      fhir:reviewOutcome [ See ClaimResponse.item.reviewOutcome ] ; # 0..1 Detail level adjudication results
      fhir:adjudication  ( [ See ClaimResponse.item.adjudication ] ... ) ; # 0..* Detail level adjudication details
      fhir:subDetail ( [ # 0..* Adjudication for claim sub-details
        fhir:subDetailSequence [ positiveInt ] ; # 1..1 Claim sub-detail instance identifier
        fhir:traceNumber  ( [ Identifier ] ... ) ; # 0..* Number for tracking
        fhir:noteNumber  ( [ positiveInt ] ... ) ; # 0..* Applicable note numbers
        fhir:reviewOutcome [ See ClaimResponse.item.reviewOutcome ] ; # 0..1 Subdetail level adjudication results
        fhir:adjudication  ( [ See ClaimResponse.item.adjudication ] ... ) ; # 0..* Subdetail level adjudication details
      ] ... ) ;
    ] ... ) ;
  ] ... ) ;
  fhir:addItem ( [ # 0..* Insurer added line items
    fhir:itemSequence  ( [ positiveInt ] ... ) ; # 0..* Item sequence number
    fhir:detailSequence  ( [ positiveInt ] ... ) ; # 0..* Detail sequence number
    fhir:subdetailSequence  ( [ positiveInt ] ... ) ; # 0..* Subdetail sequence number
    fhir:traceNumber  ( [ Identifier ] ... ) ; # 0..* Number for tracking
    fhir:provider  ( [ Reference(Organization|Practitioner|PractitionerRole) ] ... ) ; # 0..* Authorized providers
    fhir:revenue [ CodeableConcept ] ; # 0..1 Revenue or cost center code
    fhir:productOrService [ CodeableConcept ] ; # 0..1 Billing, service, product, or drug code
    fhir:productOrServiceEnd [ CodeableConcept ] ; # 0..1 End of a range of codes
    fhir:request  ( [ Reference(DeviceRequest|MedicationRequest|NutritionOrder|ServiceRequest|SupplyRequest|
  VisionPrescription) ] ... ) ; # 0..* Request or Referral for Service

    fhir:modifier  ( [ CodeableConcept ] ... ) ; # 0..* Service/Product billing modifiers
    fhir:programCode  ( [ CodeableConcept ] ... ) ; # 0..* Program the product or service is provided under
    # serviced[x] : 0..1 Date or dates of service or product delivery. One of these 2
      fhir:serviced [  a fhir:date ; date ]
      fhir:serviced [  a fhir:Period ; Period ]
    # location[x] : 0..1 Place of service or where product was supplied. One of these 3
      fhir:location [  a fhir:CodeableConcept ; CodeableConcept ]
      fhir:location [  a fhir:Address ; Address ]
      fhir:location [  a fhir:Reference ; Reference(Location) ]
    fhir:quantity [ Quantity(SimpleQuantity) ] ; # 0..1 Count of products or services
    fhir:unitPrice [ Money ] ; # 0..1 Fee, charge or cost per item
    fhir:factor [ decimal ] ; # 0..1 Price scaling factor
    fhir:tax [ Money ] ; # 0..1 Total tax
    fhir:net [ Money ] ; # 0..1 Total item cost
    fhir:bodySite ( [ # 0..* Anatomical location
      fhir:site  ( [ CodeableReference(BodyStructure) ] ... ) ; # 1..* Location
      fhir:subSite  ( [ CodeableConcept ] ... ) ; # 0..* Sub-location
    ] ... ) ;
    fhir:noteNumber  ( [ positiveInt ] ... ) ; # 0..* Applicable note numbers
    fhir:reviewOutcome [ See ClaimResponse.item.reviewOutcome ] ; # 0..1 Added items adjudication results
    fhir:adjudication  ( [ See ClaimResponse.item.adjudication ] ... ) ; # 0..* Added items adjudication
    fhir:detail ( [ # 0..* Insurer added line details
      fhir:traceNumber  ( [ Identifier ] ... ) ; # 0..* Number for tracking
      fhir:revenue [ CodeableConcept ] ; # 0..1 Revenue or cost center code
      fhir:productOrService [ CodeableConcept ] ; # 0..1 Billing, service, product, or drug code
      fhir:productOrServiceEnd [ CodeableConcept ] ; # 0..1 End of a range of codes
      fhir:modifier  ( [ CodeableConcept ] ... ) ; # 0..* Service/Product billing modifiers
      fhir:quantity [ Quantity(SimpleQuantity) ] ; # 0..1 Count of products or services
      fhir:unitPrice [ Money ] ; # 0..1 Fee, charge or cost per item
      fhir:factor [ decimal ] ; # 0..1 Price scaling factor
      fhir:tax [ Money ] ; # 0..1 Total tax
      fhir:net [ Money ] ; # 0..1 Total item cost
      fhir:noteNumber  ( [ positiveInt ] ... ) ; # 0..* Applicable note numbers
      fhir:reviewOutcome [ See ClaimResponse.item.reviewOutcome ] ; # 0..1 Added items detail level adjudication results
      fhir:adjudication  ( [ See ClaimResponse.item.adjudication ] ... ) ; # 0..* Added items detail adjudication
      fhir:subDetail ( [ # 0..* Insurer added line items
        fhir:traceNumber  ( [ Identifier ] ... ) ; # 0..* Number for tracking
        fhir:revenue [ CodeableConcept ] ; # 0..1 Revenue or cost center code
        fhir:productOrService [ CodeableConcept ] ; # 0..1 Billing, service, product, or drug code
        fhir:productOrServiceEnd [ CodeableConcept ] ; # 0..1 End of a range of codes
        fhir:modifier  ( [ CodeableConcept ] ... ) ; # 0..* Service/Product billing modifiers
        fhir:quantity [ Quantity(SimpleQuantity) ] ; # 0..1 Count of products or services
        fhir:unitPrice [ Money ] ; # 0..1 Fee, charge or cost per item
        fhir:factor [ decimal ] ; # 0..1 Price scaling factor
        fhir:tax [ Money ] ; # 0..1 Total tax
        fhir:net [ Money ] ; # 0..1 Total item cost
        fhir:noteNumber  ( [ positiveInt ] ... ) ; # 0..* Applicable note numbers
        fhir:reviewOutcome [ See ClaimResponse.item.reviewOutcome ] ; # 0..1 Added items subdetail level adjudication results
        fhir:adjudication  ( [ See ClaimResponse.item.adjudication ] ... ) ; # 0..* Added items subdetail adjudication
      ] ... ) ;
    ] ... ) ;
  ] ... ) ;
  fhir:adjudication  ( [ See ClaimResponse.item.adjudication ] ... ) ; # 0..* Header-level adjudication
  fhir:total ( [ # 0..* Adjudication totals
    fhir:category [ CodeableConcept ] ; # 1..1 Type of adjudication information
    fhir:amount [ Money ] ; # 1..1 Financial total for the category
  ] ... ) ;
  fhir:payment [ # 0..1 Payment Details
    fhir:type [ CodeableConcept ] ; # 1..1 Partial or complete payment
    fhir:adjustment [ Money ] ; # 0..1 Payment adjustment for non-claim issues
    fhir:adjustmentReason [ CodeableConcept ] ; # 0..1 Explanation for the adjustment
    fhir:date [ date ] ; # 0..1 Expected date of payment
    fhir:amount [ Money ] ; # 1..1 Payable amount after adjustment
    fhir:identifier [ Identifier ] ; # 0..1 Business identifier for the payment
  ] ;
  fhir:fundsReserve [ CodeableConcept ] ; # 0..1 Funds reserved status
  fhir:formCode [ CodeableConcept ] ; # 0..1 Printed form identifier
  fhir:form [ Attachment ] ; # 0..1 Printed reference or actual form
  fhir:processNote ( [ # 0..* Note concerning adjudication
    fhir:number [ positiveInt ] ; # 0..1 Note instance identifier
    fhir:type [ CodeableConcept ] ; # 0..1 Note purpose
    fhir:text [ string ] ; # 1..1 Note explanatory text
    fhir:language [ CodeableConcept ] ; # 0..1 Language of the text
  ] ... ) ;
  fhir:communicationRequest  ( [ Reference(CommunicationRequest) ] ... ) ; # 0..* Request for additional information
  fhir:insurance ( [ # 0..* Patient insurance information
    fhir:sequence [ positiveInt ] ; # 1..1 Insurance instance identifier
    fhir:focal [ boolean ] ; # 1..1 Coverage to be used for adjudication
    fhir:coverage [ Reference(Coverage) ] ; # 1..1 Insurance information
    fhir:businessArrangement [ string ] ; # 0..1 Additional provider contract number
    fhir:claimResponse [ Reference(ClaimResponse) ] ; # 0..1 Adjudication results
  ] ... ) ;
  fhir:error ( [ # 0..* Processing errors
    fhir:itemSequence [ positiveInt ] ; # 0..1 Item sequence number
    fhir:detailSequence [ positiveInt ] ; # 0..1 Detail sequence number
    fhir:subDetailSequence [ positiveInt ] ; # 0..1 Subdetail sequence number
    fhir:code [ CodeableConcept ] ; # 1..1 Error code detailing processing issues
    fhir:expression  ( [ string ] ... ) ; # 0..* FHIRPath of element(s) related to issue
  ] ... ) ;

]

Changes since R3 from both R4 and R4B

ClaimResponse.patient Min Cardinality changed from 0 to 1
ClaimResponse
ClaimResponse.traceNumber
  • Added Element
ClaimResponse.status ClaimResponse.insurer
  • Min Cardinality changed from 0 to 1 to 0
ClaimResponse.outcome
  • Change value set from http://hl7.org/fhir/ValueSet/fm-status http://hl7.org/fhir/ValueSet/remittance-outcome|4.0.0 to http://hl7.org/fhir/ValueSet/fm-status|4.0.1 Claim Processing Codes
ClaimResponse.type ClaimResponse.decision
  • Added Mandatory Element
ClaimResponse.subType ClaimResponse.event
  • Added Element
ClaimResponse.use ClaimResponse.event.type
  • Added Mandatory Element
ClaimResponse.created ClaimResponse.event.when[x]
  • Min Cardinality changed from 0 to 1 Added Mandatory Element
ClaimResponse.insurer ClaimResponse.encounter
  • Min Cardinality changed from 0 to 1 Added Element
ClaimResponse.requestor ClaimResponse.diagnosisRelatedGroup
  • Renamed from requestProvider to requestor Type Reference: Added Target Types PractitionerRole, Organization Element
ClaimResponse.outcome ClaimResponse.item.traceNumber
  • Min Cardinality changed from 0 to 1 Type changed from CodeableConcept to code Add Binding http://hl7.org/fhir/ValueSet/remittance-outcome|4.0.1 (required) Added Element
ClaimResponse.preAuthRef ClaimResponse.item.reviewOutcome
  • Moved from ClaimResponse.insurance to ClaimResponse Max Cardinality changed from * to 1 Added Element
ClaimResponse.preAuthPeriod ClaimResponse.item.reviewOutcome.decision
  • Added Element
ClaimResponse.item.itemSequence ClaimResponse.item.reviewOutcome.reason
  • Renamed from sequenceLinkId to itemSequence Added Element
ClaimResponse.item.adjudication ClaimResponse.item.reviewOutcome.preAuthRef
  • Min Cardinality changed from 0 to 1 Added Element
ClaimResponse.item.detail.detailSequence ClaimResponse.item.reviewOutcome.preAuthPeriod
  • Renamed from sequenceLinkId to detailSequence Added Element
ClaimResponse.item.detail.adjudication ClaimResponse.item.adjudication
  • Min Cardinality changed from 0 to 1 ClaimResponse.item.detail.subDetail.subDetailSequence Renamed from sequenceLinkId to subDetailSequence ClaimResponse.addItem.itemSequence Renamed from sequenceLinkId to itemSequence 0
ClaimResponse.addItem.detailSequence ClaimResponse.item.adjudication.quantity
  • Added Element
ClaimResponse.addItem.subdetailSequence ClaimResponse.item.detail.traceNumber
  • Added Element
ClaimResponse.addItem.provider ClaimResponse.item.detail.reviewOutcome
  • Added Element
ClaimResponse.addItem.productOrService ClaimResponse.item.detail.adjudication
    Renamed from service to productOrService
  • Min Cardinality changed from 0 to 1 to 0
ClaimResponse.addItem.programCode Added Element ClaimResponse.addItem.serviced[x] ClaimResponse.item.detail.subDetail.traceNumber
  • Added Element
ClaimResponse.addItem.location[x] ClaimResponse.item.detail.subDetail.reviewOutcome
  • Added Element
ClaimResponse.addItem.quantity ClaimResponse.addItem.traceNumber
  • Added Element
ClaimResponse.addItem.unitPrice ClaimResponse.addItem.revenue
  • Added Element
ClaimResponse.addItem.factor ClaimResponse.addItem.productOrService
  • Added Element Min Cardinality changed from 1 to 0
ClaimResponse.addItem.net ClaimResponse.addItem.productOrServiceEnd
  • Added Element
ClaimResponse.addItem.bodySite ClaimResponse.addItem.request
  • Added Element
ClaimResponse.addItem.subSite ClaimResponse.addItem.tax
  • Added Element
ClaimResponse.addItem.adjudication ClaimResponse.addItem.bodySite
  • Min Max Cardinality changed from 0 to 1 ClaimResponse.addItem.detail.productOrService Renamed from service to productOrService *
  • Min Cardinality Type changed from 0 CodeableConcept to 1 ClaimResponse.addItem.detail.quantity Added Element BackboneElement
ClaimResponse.addItem.detail.unitPrice ClaimResponse.addItem.bodySite.site
  • Added Mandatory Element
ClaimResponse.addItem.detail.factor ClaimResponse.addItem.bodySite.subSite
  • Added Element
ClaimResponse.addItem.detail.net ClaimResponse.addItem.reviewOutcome
  • Added Element
ClaimResponse.addItem.detail.adjudication ClaimResponse.addItem.adjudication
  • Min Cardinality changed from 0 to 1 to 0
ClaimResponse.addItem.detail.subDetail ClaimResponse.addItem.detail.traceNumber
  • Added Element
ClaimResponse.addItem.detail.subDetail.productOrService ClaimResponse.addItem.detail.revenue
  • Added Mandatory Element
ClaimResponse.addItem.detail.subDetail.modifier ClaimResponse.addItem.detail.productOrService
  • Added Element Min Cardinality changed from 1 to 0
ClaimResponse.addItem.detail.subDetail.quantity ClaimResponse.addItem.detail.productOrServiceEnd
  • Added Element
ClaimResponse.addItem.detail.subDetail.unitPrice ClaimResponse.addItem.detail.tax
  • Added Element
ClaimResponse.addItem.detail.subDetail.factor ClaimResponse.addItem.detail.reviewOutcome
  • Added Element
ClaimResponse.addItem.detail.subDetail.net ClaimResponse.addItem.detail.adjudication
  • Added Element Min Cardinality changed from 1 to 0
ClaimResponse.addItem.detail.subDetail.noteNumber ClaimResponse.addItem.detail.subDetail.traceNumber
  • Added Element
ClaimResponse.addItem.detail.subDetail.adjudication ClaimResponse.addItem.detail.subDetail.revenue
  • Added Mandatory Element
ClaimResponse.adjudication ClaimResponse.addItem.detail.subDetail.productOrService
  • Added Element Min Cardinality changed from 1 to 0
ClaimResponse.total ClaimResponse.addItem.detail.subDetail.productOrServiceEnd
  • Added Element
ClaimResponse.total.category ClaimResponse.addItem.detail.subDetail.tax
  • Added Mandatory Element
ClaimResponse.total.amount ClaimResponse.addItem.detail.subDetail.reviewOutcome
  • Added Mandatory Element
ClaimResponse.payment.type ClaimResponse.addItem.detail.subDetail.adjudication
  • Min Cardinality changed from 0 to 1 ClaimResponse.payment.amount Min Cardinality changed from 0 to 1 ClaimResponse.fundsReserve Renamed from reserved to fundsReserve Type changed from Coding to CodeableConcept ClaimResponse.formCode Added Element ClaimResponse.form Type changed from CodeableConcept to Attachment 0
ClaimResponse.processNote.type
  • Type changed from CodeableConcept to code Change value set from http://hl7.org/fhir/ValueSet/note-type to http://hl7.org/fhir/ValueSet/note-type|4.0.1 CodeableConcept
    • ClaimResponse.processNote.text
  • Min Cardinality changed Change binding strength from 0 required to 1 extensible
ClaimResponse.processNote.language
  • Change binding strength from extensible to preferred ClaimResponse.error.itemSequence Renamed from sequenceLinkId to itemSequence required
    • ClaimResponse.error.detailSequence
  • Renamed Change value set from detailSequenceLinkId Common Languages to detailSequence All Languages
    • ClaimResponse.error.subDetailSequence
  • Renamed Change max value set from subdetailSequenceLinkId All Languages to subDetailSequence ClaimResponse.requestOrganization deleted ClaimResponse.addItem.revenue deleted ClaimResponse.addItem.category deleted ClaimResponse.addItem.fee deleted ClaimResponse.addItem.detail.revenue deleted ClaimResponse.addItem.detail.category deleted ClaimResponse.addItem.detail.fee deleted none
ClaimResponse.totalCost ClaimResponse.error.expression
  • deleted Added Element
ClaimResponse.unallocDeductable ClaimResponse.item.adjudication.value
  • deleted Deleted
ClaimResponse.totalBenefit ClaimResponse.addItem.subSite
  • deleted Deleted

See the Full Difference for further information

This analysis is available for R4 as XML or JSON and for R4B as XML or JSON .

See R3 <--> R4 <--> R5 Conversion Maps (status = 1 test that all execute ok. 1 fail round-trip testing and 1 r3 resources are invalid (0 errors). ) See Conversions Summary .)

Structure

1..1 Money Anatomical sub-location
Name Flags Card. Type Description & Constraints doco
. . ClaimResponse TU DomainResource Response to a claim predetermination or preauthorization

Elements defined in Ancestors: id , meta , implicitRules , language , text , contained , extension , modifierExtension
. . . identifier 0..* Identifier Business Identifier for a claim response

. . status . traceNumber 0..* Identifier Number for tracking

... status ?! Σ 1..1 code active | cancelled | draft | entered-in-error
Binding: Financial Resource Status Codes ( Required )
. . . type Σ 1..1 CodeableConcept More granular claim type
Binding: Claim Type Codes ( Extensible )
. . . subType 0..1 CodeableConcept More granular claim type
Binding: Example Claim SubType Codes ( Example )
. . . use Σ 1..1 code claim | preauthorization | predetermination
Binding: Use ( Required )
. . . patient Σ 1..1 Reference ( Patient ) The recipient of the products and services
. . . created Σ 1..1 dateTime Response creation date
. . . insurer Σ 0..1 Reference ( Organization ) Party responsible for reimbursement
. . . requestor 0..1 Reference ( Practitioner | PractitionerRole | Organization ) Party responsible for the claim
. . . request Σ 0..1 Reference ( Claim ) Id of resource triggering adjudication
. . . outcome Σ 1..1 code queued | complete | error | partial
Binding: Claim Processing Codes ( Required )
. . . decision Σ 0..1 CodeableConcept Result of the adjudication
Binding: Claim Adjudication Decision Codes ( Example )
. . . disposition 0..1 string Disposition Message
. . . preAuthRef 0..1 string Preauthorization reference
. . . preAuthPeriod 0..1 Period Preauthorization reference effective period
. . . event 0..* BackboneElement Event information

.. . payeeType . type 1..1 CodeableConcept Specific event
Binding: Dates Type Codes ( Example )
.... when[x] 1..1 0..1 Occurance date or period
..... whenDateTime dateTime
..... whenPeriod Period
... payeeType 0..1 CodeableConcept Party to be paid any benefits payable
PayeeType Binding: Claim Payee Type Codes ( Example )
. . item . encounter 0..* Reference ( Encounter ) Encounters associated with the listed treatments

... diagnosisRelatedGroup 0..1 CodeableConcept Package billing code
Binding: Example Diagnosis Related Group Codes ( Example )
... item 0..* BackboneElement Adjudication for claim line items

. . . . itemSequence 1..1 positiveInt Claim item instance identifier
. . . . traceNumber 0..* Identifier Number for tracking

. . . . noteNumber 0..* positiveInt Applicable note numbers

. . . . adjudication reviewOutcome 1..* 0..1 BackboneElement Adjudication details results
. . . . . category decision 1..1 0..1 CodeableConcept Type Result of the adjudication information
Binding: Claim Adjudication Value Decision Codes ( Example )
. . . . . reason 0..1 0..* CodeableConcept Explanation Reason for result of the adjudication outcome
Binding: Claim Adjudication Decision Reason Codes ( Example )

. . . . amount . preAuthRef 0..1 string Preauthorization reference
..... preAuthPeriod 0..1 Period Preauthorization reference effective period
.... adjudication 0..* BackboneElement Monetary amount Adjudication details

. . . . value . category 1..1 CodeableConcept Type of adjudication information
Binding: Adjudication Value Codes ( Example )
..... reason 0..1 CodeableConcept Explanation of adjudication outcome
Binding: Adjudication Reason Codes ( Example )
..... amount 0..1 decimal Money Non-monetary value Monetary amount
. . . . detail . quantity 0..1 Quantity Non-monetary value
.... detail 0..* BackboneElement Adjudication for claim details

. . . . . detailSequence 1..1 positiveInt Claim detail instance identifier
. . . . . traceNumber 0..* Identifier Number for tracking

. . . . . noteNumber 0..* positiveInt Applicable note numbers

. . . . . adjudication reviewOutcome 1..* 0..1 see adjudication reviewOutcome Detail level adjudication details results
. . . . subDetail . adjudication 0..* see adjudication Detail level adjudication details

..... subDetail 0..* BackboneElement Adjudication for claim sub-details

. . . . . . subDetailSequence 1..1 positiveInt Claim sub-detail instance identifier
. . . . . . traceNumber 0..* Identifier Number for tracking

. . . . . . noteNumber 0..* positiveInt Applicable note numbers

. . . . . . adjudication reviewOutcome 0..1 see reviewOutcome Subdetail level adjudication results
...... adjudication 0..* see adjudication Subdetail level adjudication details

. . . addItem 0..* BackboneElement Insurer added line items

. . . . itemSequence 0..* positiveInt Item sequence number

.... detailSequence 0..* positiveInt Item Detail sequence number

. . . . detailSequence subdetailSequence 0..* positiveInt Detail Subdetail sequence number

. . . subdetailSequence . traceNumber 0..* positiveInt Identifier Subdetail sequence number Number for tracking

. . . . provider 0..* Reference ( Practitioner | PractitionerRole | Organization ) Authorized providers

. . . . productOrService revenue 0..1 1..1 CodeableConcept Revenue or cost center code
Binding: Example Revenue Center Codes ( Example )
.... productOrService 0..1 CodeableConcept Billing, service, product, or drug code
Binding: USCLS Codes ( Example )
. . . . productOrServiceEnd 0..1 CodeableConcept End of a range of codes
Binding: USCLS Codes ( Example )
. . . modifier . request 0..* Reference ( DeviceRequest | MedicationRequest | NutritionOrder | ServiceRequest | SupplyRequest | VisionPrescription ) Request or Referral for Service

.... modifier 0..* CodeableConcept Service/Product billing modifiers
Binding: Modifier type Codes ( Example )

. . . . programCode 0..* CodeableConcept Program the product or service is provided under
Binding: Example Program Reason Codes ( Example )

. . . . serviced[x] 0..1 Date or dates of service or product delivery
. . . . . servicedDate date
. . . . . servicedPeriod Period
. . . . location[x] 0..1 Place of service or where product was supplied
Binding: Example Service Place Codes ( Example )
. . . . . locationCodeableConcept CodeableConcept
. . . . . locationAddress Address
. . . . . locationReference Reference ( Location )
. . . . quantity 0..1 SimpleQuantity Count of products or services
. . . . unitPrice 0..1 Money Fee, charge or cost per item
. . . . factor 0..1 decimal Price scaling factor
. . . . tax 0..1 Money Total tax
. . . . net 0..1 Money Total item cost
. . . . bodySite 0..1 0..* CodeableConcept BackboneElement Anatomical location

. . . . . site 1..* CodeableReference ( BodyStructure ) Location
Binding: Oral Site Codes ( Example )

. . . . . subSite 0..* CodeableConcept Sub-location
Binding: Surface Codes ( Example )

. . . . noteNumber 0..* positiveInt Applicable note numbers

. . . . reviewOutcome 0..1 see reviewOutcome Added items adjudication results
. . . . adjudication 1..* 0..* see adjudication Added items adjudication

. . . . detail 0..* BackboneElement Insurer added line details

. . . . . productOrService traceNumber 0..* Identifier 1..1 Number for tracking

..... revenue 0..1 CodeableConcept Revenue or cost center code
Binding: Example Revenue Center Codes ( Example )
..... productOrService 0..1 CodeableConcept Billing, service, product, or drug code
Binding: USCLS Codes ( Example )
. . . . . modifier productOrServiceEnd 0..1 CodeableConcept End of a range of codes
Binding: USCLS Codes ( Example )
..... modifier 0..* CodeableConcept Service/Product billing modifiers
Binding: Modifier type Codes ( Example )

. . . . . quantity 0..1 SimpleQuantity Count of products or services
. . . . . unitPrice 0..1 Money Fee, charge or cost per item
. . . . . factor 0..1 decimal Price scaling factor
. . . . . tax 0..1 Money Total tax
. . . . . net 0..1 Money Total item cost
. . . . . noteNumber 0..* positiveInt Applicable note numbers

. . . . . adjudication reviewOutcome 1..* 0..1 see adjudication reviewOutcome Added items detail level adjudication results
. . . . subDetail . adjudication 0..* see adjudication Added items detail adjudication

..... subDetail 0..* BackboneElement Insurer added line items

. . . . . . traceNumber 0..* Identifier Number for tracking

. . . . . . productOrService revenue 0..1 1..1 CodeableConcept Revenue or cost center code
Binding: Example Revenue Center Codes ( Example )
...... productOrService 0..1 CodeableConcept Billing, service, product, or drug code
Binding: USCLS Codes ( Example )
. . . . . . productOrServiceEnd 0..1 CodeableConcept End of a range of codes
Binding: USCLS Codes ( Example )
. . . . . . modifier 0..* CodeableConcept Service/Product billing modifiers
Binding: Modifier type Codes ( Example )

. . . . . . quantity 0..1 SimpleQuantity Count of products or services
. . . . . . unitPrice 0..1 Money Fee, charge or cost per item
. . . . . . factor 0..1 decimal Price scaling factor
. . . . . . net tax 0..1 Money Total item cost tax
. . . . . noteNumber . net 0..1 Money Total item cost
...... noteNumber 0..* positiveInt Applicable note numbers

. . . . . . reviewOutcome 0..1 see reviewOutcome Added items subdetail level adjudication results
. . . . . . adjudication 1..* 0..* see adjudication Added items detail subdetail adjudication

. . . adjudication 0..* see adjudication Header-level adjudication

. . . total Σ 0..* BackboneElement Adjudication totals

. . . . category Σ 1..1 CodeableConcept Type of adjudication information
Binding: Adjudication Value Codes ( Example )
. . . . amount Σ 1..1 Money Financial total for the category
. . . payment 0..1 BackboneElement Payment Details
. . . . type 1..1 CodeableConcept Partial or complete payment
Binding: Example Payment Type Codes ( Example )
. . . . adjustment 0..1 Money Payment adjustment for non-claim issues
. . . . adjustmentReason 0..1 CodeableConcept Explanation for the adjustment
Binding: Payment Adjustment Reason Codes ( Example )
. . . . date 0..1 date Expected date of payment
. . . . amount 1..1 Money Payable amount after adjustment
. . . . identifier 0..1 Identifier Business identifier for the payment
. . . fundsReserve 0..1 CodeableConcept Funds reserved status
FundsReserve Binding: Funds Reservation Codes ( Example )
. . . formCode 0..1 CodeableConcept Printed form identifier
Forms Binding: Form Codes ( Example )
. . . form 0..1 Attachment Printed reference or actual form
. . . processNote 0..* BackboneElement Note concerning adjudication

. . . . number 0..1 positiveInt Note instance identifier
. . . . type 0..1 code CodeableConcept display | print | printoper Note purpose
Binding: NoteType ( Required Extensible )
. . . . text 1..1 string Note explanatory text
. . . . language 0..1 CodeableConcept Language of the text
Common Binding: All Languages ( Preferred but limited to AllLanguages Required )
Additional Bindings Purpose
Common Languages Starter Set

. . . communicationRequest 0..* Reference ( CommunicationRequest ) Request for additional information

. . . insurance 0..* BackboneElement Patient insurance information

. . . . sequence 1..1 positiveInt Insurance instance identifier
. . . . focal 1..1 boolean Coverage to be used for adjudication
. . . . coverage 1..1 Reference ( Coverage ) Insurance information
. . . . businessArrangement 0..1 string Additional provider contract number
. . . . claimResponse 0..1 Reference ( ClaimResponse ) Adjudication results
. . . error 0..* BackboneElement Processing errors

. . . . itemSequence 0..1 positiveInt Item sequence number
. . . . detailSequence 0..1 positiveInt Detail sequence number
. . . . subDetailSequence 0..1 positiveInt Subdetail sequence number
. . . . code Σ 1..1 CodeableConcept Error code detailing processing issues
AdjudicationError Binding: Adjudication Error Codes ( Example )
. . . . expression Σ 0..* string FHIRPath of element(s) related to issue


doco Documentation for this format icon

See the Extensions for this resource

UML Diagram ( Legend )

ClaimResponse ( DomainResource ) A unique identifier assigned to this claim response identifier : Identifier [0..*] Trace number for tracking purposes. May be defined at the jurisdiction level or between trading partners traceNumber : Identifier [0..*] The status of the resource instance (this element modifies the meaning of other elements) status : code [1..1] « A code specifying the state of the resource instance. null (Strength=Required) FinancialResourceStatusCodes ! » A finer grained suite of claim type codes which may convey additional information such as Inpatient vs Outpatient and/or a specialty service type : CodeableConcept [1..1] « The type or discipline-style of the claim. null (Strength=Extensible) ClaimTypeCodes + » A finer grained suite of claim type codes which may convey additional information such as Inpatient vs Outpatient and/or a specialty service subType : CodeableConcept [0..1] « A more granular claim typecode. null (Strength=Example) ExampleClaimSubTypeCodes ?? » A code to indicate whether the nature of the request is: to Claim - A request adjudication of products to an Insurer to adjudicate the supplied charges for health care goods and services previously rendered; or requesting authorization under the identified policy and adjudication to pay the determined Benefit amount, if any; Preauthorization - A request to an Insurer to adjudicate the supplied proposed future charges for provision in health care goods and services under the future; or requesting identified policy and to approve the non-binding adjudication of services and provide the listed products expected benefit amounts and potentially to reserve funds to pay the benefits when Claims for the indicated services are later submitted; or, Pre-determination - A request to an Insurer to adjudicate the supplied 'what if' charges for health care goods and services which could under the identified policy and report back what the Benefit payable would be provided in had the future services actually been provided use : code [1..1] « Claim, preauthorization, predetermination. null (Strength=Required) Use ! » The 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 patient : Reference [1..1] « Patient » The date this resource was created created : dateTime [1..1] The party responsible for authorization, adjudication and reimbursement insurer : Reference [1..1] [0..1] « Organization » The provider which is responsible for the claim, predetermination or preauthorization requestor : Reference [0..1] « Practitioner | PractitionerRole | Organization » Original request resource reference request : Reference [0..1] « Claim » The outcome of the claim, predetermination, or preauthorization processing outcome : code [1..1] « null (Strength=Required) ClaimProcessingCodes ! » The result of the claim processing. (Strength=Required) claim, predetermination, or preauthorization adjudication ClaimProcessingCodes ! decision : CodeableConcept [0..1] « null (Strength=Example) ClaimAdjudicationDecisionsCod... ?? » A human readable description of the status of the adjudication disposition : string [0..1] Reference from the Insurer which is used in later communications which refers to this adjudication preAuthRef : string [0..1] The time frame during which this authorization is effective preAuthPeriod : Period [0..1] Type of Party to be reimbursed: subscriber, provider, other payeeType : CodeableConcept [0..1] « null (Strength=Example) ClaimPayeeTypeCodes ?? » Healthcare encounters related to this claim encounter : Reference [0..*] « Encounter » A package billing code for the party or bundle code used to be reimbursed. group products and services to a particular health condition (such as heart attack) which is based on a predetermined grouping code system diagnosisRelatedGroup : CodeableConcept [0..1] « null (Strength=Example) Claim Payee Type ExampleDiagnosisRelatedGroupC... ?? » A code, used only on a response to a preauthorization, to indicate whether the benefits payable have been reserved and for whom fundsReserve : CodeableConcept [0..1] « For whom funds are to be reserved: (Patient, Provider, None). null (Strength=Example) Funds Reservation FundsReservationCodes ?? » A code for the form to be used for printing the content formCode : CodeableConcept [0..1] « The forms codes. null (Strength=Example) Form FormCodes ?? » The actual form, by reference or inclusion, for printing the content or an EOB form : Attachment [0..1] Request for additional supporting or authorizing information communicationRequest : Reference [0..*] « CommunicationRequest » Event A coded event such as when a service is expected or a card printed type : CodeableConcept [1..1] « null (Strength=Example) DatesTypeCodes ?? » A date or period in the past or future indicating when the event occurred or is expectd to occur when[x] : DataType [1..1] « dateTime | Period » Item A number to uniquely reference the claim item entries itemSequence : positiveInt [1..1] Trace number for tracking purposes. May be defined at the jurisdiction level or between trading partners traceNumber : Identifier [0..*] The numbers associated with notes below which apply to the adjudication of this item noteNumber : positiveInt [0..*] ReviewOutcome The result of the claim, predetermination, or preauthorization adjudication decision : CodeableConcept [0..1] « null (Strength=Example) ClaimAdjudicationDecisionsCod... ?? » The reasons for the result of the claim, predetermination, or preauthorization adjudication reason : CodeableConcept [0..*] « null (Strength=Example) ClaimAdjudicationDecisionReas... ?? » Reference from the Insurer which is used in later communications which refers to this adjudication preAuthRef : string [0..1] The time frame during which this authorization is effective preAuthPeriod : Period [0..1] Adjudication 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 category : CodeableConcept [1..1] « The adjudication codes. null (Strength=Example) AdjudicationValueCodes ?? » A code supporting the understanding of the adjudication result and explaining variance from expected amount reason : CodeableConcept [0..1] « The adjudication reason codes. null (Strength=Example) AdjudicationReasonCodes ?? » Monetary amount associated with the category amount : Money [0..1] A non-monetary value associated with the category. Mutually exclusive to the amount element above value quantity : decimal Quantity [0..1] ItemDetail A number to uniquely reference the claim detail entry detailSequence : positiveInt [1..1] Trace number for tracking purposes. May be defined at the jurisdiction level or between trading partners traceNumber : Identifier [0..*] The numbers associated with notes below which apply to the adjudication of this item noteNumber : positiveInt [0..*] SubDetail A number to uniquely reference the claim sub-detail entry subDetailSequence : positiveInt [1..1] Trace number for tracking purposes. May be defined at the jurisdiction level or between trading partners traceNumber : Identifier [0..*] The numbers associated with notes below which apply to the adjudication of this item noteNumber : positiveInt [0..*] AddedItem Claim items which this service line is intended to replace itemSequence : positiveInt [0..*] The sequence number of the details within the claim item which this line is intended to replace detailSequence : positiveInt [0..*] The sequence number of the sub-details within the details within the claim item which this line is intended to replace subdetailSequence : positiveInt [0..*] Trace number for tracking purposes. May be defined at the jurisdiction level or between trading partners traceNumber : Identifier [0..*] The providers who are authorized for the services rendered to the patient provider : Reference [0..*] « Practitioner | PractitionerRole | Organization » The type of revenue or cost center providing the product and/or service revenue : CodeableConcept [0..1] « null (Strength=Example) ExampleRevenueCenterCodes ?? » When the value is a group code then this item collects a set of related claim item details, otherwise this contains the product, service, drug or other billing code for the item item. This element may be the start of a range of .productOrService codes used in conjunction with .productOrServiceEnd or it may be a solo element where .productOrServiceEnd is not used productOrService : CodeableConcept [1..1] [0..1] « Allowable service null (Strength=Example) USCLSCodes ?? » This contains the end of a range of product, service, drug or other billing codes for the item. This element is not used when the .productOrService is a group code. This value may only be present when a .productOfService code has been provided to convey the start of the range. Typically this value may be used only with preauthorizations and product codes. not with claims productOrServiceEnd : CodeableConcept [0..1] « null (Strength=Example) USCLSCodes ?? » Request or Referral for Goods or Service to be rendered request : Reference [0..*] « DeviceRequest | MedicationRequest | NutritionOrder | ServiceRequest | SupplyRequest | VisionPrescription » Item typification or modifiers codes to convey additional context for the product or service modifier : CodeableConcept [0..*] « Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen. null (Strength=Example) ModifierTypeCodes ?? » Identifies the program under which this may be recovered programCode : CodeableConcept [0..*] « Program specific reason codes. null (Strength=Example) ExampleProgramReasonCodes ?? » The date or dates when the service or product was supplied, performed or completed serviced[x] : Type DataType [0..1] « date | Period » Where the product or service was provided location[x] : Type DataType [0..1] « CodeableConcept | Address | Reference ( Location ); Place of service: pharmacy, school, prison, etc. null (Strength=Example) ExampleServicePlaceCodes ?? » The number of repetitions of a service or product quantity : Quantity ( SimpleQuantity ) [0..1] 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 unitPrice : Money [0..1] A real number that represents a multiplier used in determining the overall value of services delivered and/or goods received. The concept of a Factor allows for a discount or surcharge multiplier to be applied to a monetary amount factor : decimal [0..1] The quantity times the unit price total of taxes applicable for an additional service or this product or charge service tax : Money [0..1] The total amount claimed for the group (if a grouper) or the addItem. Net = unit price * quantity * factor net : Money [0..1] The numbers associated with notes below which apply to the adjudication of this item noteNumber : positiveInt [0..*] BodySite Physical service site on the patient (limb, tooth, etc.) bodySite site : CodeableConcept CodeableReference [0..1] [1..*] « BodyStructure ; The code for the teeth, quadrant, sextant and arch. null (Strength=Example) OralSiteCodes ?? » A region or surface of the bodySite, e.g. limb region or tooth surface(s) subSite : CodeableConcept [0..*] « The code for the tooth surface and surface combinations. null (Strength=Example) SurfaceCodes ?? » AddedItemDetail The numbers associated with notes below which apply to Trace number for tracking purposes. May be defined at the adjudication of this item jurisdiction level or between trading partners noteNumber traceNumber : positiveInt Identifier [0..*] The type of revenue or cost center providing the product and/or service revenue : CodeableConcept [0..1] « AddedItemDetail null (Strength=Example) ExampleRevenueCenterCodes ?? » When the value is a group code then this item collects a set of related claim item details, otherwise this contains the product, service, drug or other billing code for the item item. This element may be the start of a range of .productOrService codes used in conjunction with .productOrServiceEnd or it may be a solo element where .productOrServiceEnd is not used productOrService : CodeableConcept [1..1] [0..1] « Allowable service null (Strength=Example) USCLSCodes ?? » This contains the end of a range of product, service, drug or other billing codes for the item. This element is not used when the .productOrService is a group code. This value may only be present when a .productOfService code has been provided to convey the start of the range. Typically this value may be used only with preauthorizations and product codes. not with claims productOrServiceEnd : CodeableConcept [0..1] « null (Strength=Example) USCLSCodes ?? » Item typification or modifiers codes to convey additional context for the product or service modifier : CodeableConcept [0..*] « Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen. null (Strength=Example) ModifierTypeCodes ?? » The number of repetitions of a service or product quantity : Quantity ( SimpleQuantity ) [0..1] 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 unitPrice : Money [0..1] A real number that represents a multiplier used in determining the overall value of services delivered and/or goods received. The concept of a Factor allows for a discount or surcharge multiplier to be applied to a monetary amount factor : decimal [0..1] The quantity times the unit price total of taxes applicable for an additional service or this product or charge service tax : Money [0..1] The total amount claimed for the group (if a grouper) or the addItem.detail. Net = unit price * quantity * factor net : Money [0..1] The numbers associated with notes below which apply to the adjudication of this item noteNumber : positiveInt [0..*] AddedItemSubDetail AddedItemSubDetail Trace number for tracking purposes. May be defined at the jurisdiction level or between trading partners traceNumber : Identifier [0..*] The type of revenue or cost center providing the product and/or service revenue : CodeableConcept [0..1] « null (Strength=Example) ExampleRevenueCenterCodes ?? » When the value is a group code then this item collects a set of related claim item details, otherwise this contains the product, service, drug or other billing code for the item item. This element may be the start of a range of .productOrService codes used in conjunction with .productOrServiceEnd or it may be a solo element where .productOrServiceEnd is not used productOrService : CodeableConcept [1..1] [0..1] « Allowable service null (Strength=Example) USCLSCodes ?? » This contains the end of a range of product, service, drug or other billing codes for the item. This element is not used when the .productOrService is a group code. This value may only be present when a .productOfService code has been provided to convey the start of the range. Typically this value may be used only with preauthorizations and product codes. not with claims productOrServiceEnd : CodeableConcept [0..1] « null (Strength=Example) USCLSCodes ?? » Item typification or modifiers codes to convey additional context for the product or service modifier : CodeableConcept [0..*] « Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen. null (Strength=Example) ModifierTypeCodes ?? » The number of repetitions of a service or product quantity : Quantity ( SimpleQuantity ) [0..1] 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 unitPrice : Money [0..1] A real number that represents a multiplier used in determining the overall value of services delivered and/or goods received. The concept of a Factor allows for a discount or surcharge multiplier to be applied to a monetary amount factor : decimal [0..1] The quantity times the unit price total of taxes applicable for an additional service or this product or charge service tax : Money [0..1] The total amount claimed for the addItem.detail.subDetail. Net = unit price * quantity * factor net : Money [0..1] The numbers associated with notes below which apply to the adjudication of this item noteNumber : positiveInt [0..*] Total 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 category : CodeableConcept [1..1] « The adjudication codes. null (Strength=Example) AdjudicationValueCodes ?? » Monetary total amount associated with the category amount : Money [1..1] Payment Whether this represents partial or complete payment of the benefits payable type : CodeableConcept [1..1] « The type (partial, complete) of the payment. null (Strength=Example) ExamplePaymentTypeCodes ?? » Total amount of all adjustments to this payment included in this transaction which are not related to this claim's adjudication adjustment : Money [0..1] Reason for the payment adjustment adjustmentReason : CodeableConcept [0..1] « Payment Adjustment reason codes. null (Strength=Example) PaymentAdjustmentReasonCodes ?? » Estimated date the payment will be issued or the actual issue date of payment date : date [0..1] Benefits payable less any payment adjustment amount : Money [1..1] Issuer's unique identifier for the payment instrument identifier : Identifier [0..1] Note A number to uniquely identify a note entry number : positiveInt [0..1] The business purpose of the note text type : code CodeableConcept [0..1] « The presentation types of notes. (Strength=Required) null (Strength=Extensible) NoteType ! + » The explanation or description associated with the processing text : string [1..1] A code to define the language used in the text of the note language : CodeableConcept [0..1] « A human language. (Strength=Preferred) null (Strength=Required) CommonLanguages ? AllLanguages ! » Insurance A number to uniquely identify insurance entries and provide a sequence of coverages to convey coordination of benefit order sequence : positiveInt [1..1] A flag to indicate that this Coverage is to be used for adjudication of this claim when set to true focal : boolean [1..1] Reference to the 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 coverage : Reference [1..1] « Coverage » A business agreement number established between the provider and the insurer for special business processing purposes businessArrangement : string [0..1] The result of the adjudication of the line items for the Coverage specified in this insurance claimResponse : Reference [0..1] « ClaimResponse » Error The sequence number of the line item submitted which contains the error. This value is omitted when the error occurs outside of the item structure itemSequence : positiveInt [0..1] The 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 detailSequence : positiveInt [0..1] 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 subDetailSequence : positiveInt [0..1] An error code, from a specified code system, which details why the claim could not be adjudicated code : CodeableConcept [1..1] « The adjudication error codes. null (Strength=Example) Adjudication Error AdjudicationErrorCodes ?? » A [simple subset of FHIRPath](fhirpath.html#simple) limited to element names, repetition indicators and the default child accessor that identifies one of the elements in the resource that caused this issue to be raised expression : string [0..*] Information code for an event with a corresponding date or period event [0..*] The high-level results of the adjudication if adjudication has been performed reviewOutcome [0..1] If this item is a group then the values here are a summary of the adjudication of the detail items. If this item is a simple product or service then this is the result of the adjudication of this item adjudication [1..*] [0..*] The high-level results of the adjudication if adjudication has been performed reviewOutcome [0..1] The adjudication results adjudication [1..*] [0..*] The high-level results of the adjudication if adjudication has been performed reviewOutcome [0..1] The adjudication results adjudication [0..*] A sub-detail adjudication of a simple product or service subDetail [0..*] A claim detail. Either a simple (a product or service) or a 'group' of sub-details which are simple items detail [0..*] 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 item [0..*] Physical location where the service is performed or applies bodySite [0..*] The high-level results of the adjudication if adjudication has been performed reviewOutcome [0..1] The adjudication results adjudication [1..*] [0..*] The high-level results of the adjudication if adjudication has been performed reviewOutcome [0..1] The adjudication results adjudication [1..*] [0..*] The high-level results of the adjudication if adjudication has been performed reviewOutcome [0..1] The adjudication results adjudication [1..*] [0..*] The third-tier service adjudications for payor added services subDetail [0..*] The second-tier service adjudications for payor added services detail [0..*] The first-tier service adjudications for payor added product or service lines addItem [0..*] The adjudication results which are presented at the header level rather than at the line-item or add-item levels adjudication [0..*] Categorized monetary totals for the adjudication total [0..*] Payment details for the adjudication of the claim payment [0..1] A note that describes or explains adjudication results in a human readable form processNote [0..*] Financial instruments for reimbursement for the health care products and services specified on the claim insurance [0..*] Errors encountered during the processing of the adjudication error [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 Business Identifier for a claim response --></identifier>
 <traceNumber><!-- 0..* Identifier Number for tracking --></traceNumber>

 <status value="[code]"/><!-- 1..1 active | cancelled | draft | entered-in-error -->
 <type><!-- 1..1 CodeableConcept More granular claim type --></type>
 <subType><!-- 0..1 CodeableConcept More granular claim type --></subType>
 <

 <use value="[code]"/><!-- 1..1 claim | preauthorization | predetermination -->

 <patient><!-- 1..1 Reference(Patient) The recipient of the products and services --></patient>
 <created value="[dateTime]"/><!-- 1..1 Response creation date -->
 <</insurer>
 <</requestor>

 <insurer><!-- 0..1 Reference(Organization) Party responsible for reimbursement --></insurer>
 <requestor><!-- 0..1 Reference(Organization|Practitioner|PractitionerRole) Party responsible for the claim --></requestor>

 <request><!-- 0..1 Reference(Claim) Id of resource triggering adjudication --></request>
 <

 <outcome value="[code]"/><!-- 1..1 queued | complete | error | partial -->
 <decision><!-- 0..1 CodeableConcept Result of the adjudication --></decision>

 <disposition value="[string]"/><!-- 0..1 Disposition Message -->
 <preAuthRef value="[string]"/><!-- 0..1 Preauthorization reference -->
 <preAuthPeriod><!-- 0..1 Period Preauthorization reference effective period --></preAuthPeriod>
 <event>  <!-- 0..* Event information -->
  <type><!-- 1..1 CodeableConcept Specific event --></type>
  <when[x]><!-- 1..1 dateTime|Period Occurance date or period --></when[x]>
 </event>

 <payeeType><!-- 0..1 CodeableConcept Party to be paid any benefits payable --></payeeType>
 <encounter><!-- 0..* Reference(Encounter) Encounters associated with the listed treatments --></encounter>
 <diagnosisRelatedGroup><!-- 0..1 CodeableConcept Package billing code --></diagnosisRelatedGroup>

 <item>  <!-- 0..* Adjudication for claim line items -->
  <itemSequence value="[positiveInt]"/><!-- 1..1 Claim item instance identifier -->
  <traceNumber><!-- 0..* Identifier Number for tracking --></traceNumber>

  <noteNumber value="[positiveInt]"/><!-- 0..* Applicable note numbers -->
  <

  <reviewOutcome>  <!-- 0..1 Adjudication results -->
   <decision><!-- 0..1 CodeableConcept Result of the adjudication --></decision>
   <reason><!-- 0..* CodeableConcept Reason for result of the adjudication --></reason>
   <preAuthRef value="[string]"/><!-- 0..1 Preauthorization reference -->
   <preAuthPeriod><!-- 0..1 Period Preauthorization reference effective period --></preAuthPeriod>
  </reviewOutcome>
  <adjudication>  <!-- 0..* Adjudication details -->

   <category><!-- 1..1 CodeableConcept Type of adjudication information --></category>
   <reason><!-- 0..1 CodeableConcept Explanation of adjudication outcome --></reason>
   <amount><!-- 0..1 Money Monetary amount --></amount>
   <

   <quantity><!-- 0..1 Quantity Non-monetary value --></quantity>

  </adjudication>
  <detail>  <!-- 0..* Adjudication for claim details -->
   <detailSequence value="[positiveInt]"/><!-- 1..1 Claim detail instance identifier -->
   <traceNumber><!-- 0..* Identifier Number for tracking --></traceNumber>

   <noteNumber value="[positiveInt]"/><!-- 0..* Applicable note numbers -->
   <</adjudication>

   <reviewOutcome><!-- 0..1 Content as for ClaimResponse.item.reviewOutcome Detail level adjudication results --></reviewOutcome>
   <adjudication><!-- 0..* Content as for ClaimResponse.item.adjudication Detail level adjudication details --></adjudication>

   <subDetail>  <!-- 0..* Adjudication for claim sub-details -->
    <subDetailSequence value="[positiveInt]"/><!-- 1..1 Claim sub-detail instance identifier -->
    <traceNumber><!-- 0..* Identifier Number for tracking --></traceNumber>

    <noteNumber value="[positiveInt]"/><!-- 0..* Applicable note numbers -->
    <reviewOutcome><!-- 0..1 Content as for ClaimResponse.item.reviewOutcome Subdetail level adjudication results --></reviewOutcome>

    <adjudication><!-- 0..* Content as for ClaimResponse.item.adjudication Subdetail level adjudication details --></adjudication>
   </subDetail>
  </detail>
 </item>
 <addItem>  <!-- 0..* Insurer added line items -->
  <itemSequence value="[positiveInt]"/><!-- 0..* Item sequence number -->
  <detailSequence value="[positiveInt]"/><!-- 0..* Detail sequence number -->
  <subdetailSequence value="[positiveInt]"/><!-- 0..* Subdetail sequence number -->
  <</provider>
  <</productOrService>

  <traceNumber><!-- 0..* Identifier Number for tracking --></traceNumber>
  <provider><!-- 0..* Reference(Organization|Practitioner|PractitionerRole) Authorized providers --></provider>
  <revenue><!-- 0..1 CodeableConcept Revenue or cost center code --></revenue>
  <productOrService><!-- 0..1 CodeableConcept Billing, service, product, or drug code --></productOrService>
  <productOrServiceEnd><!-- 0..1 CodeableConcept End of a range of codes --></productOrServiceEnd>
  <request><!-- 0..* Reference(DeviceRequest|MedicationRequest|NutritionOrder|
    ServiceRequest|SupplyRequest|VisionPrescription) Request or Referral for Service --></request>
  <modifier><!-- 0..* CodeableConcept Service/Product billing modifiers --></modifier>
  <programCode><!-- 0..* CodeableConcept Program the product or service is provided under --></programCode>
  <serviced[x]><!-- 0..1 date|Period Date or dates of service or product delivery --></serviced[x]>
  <location[x]><!-- 0..1 CodeableConcept|Address|Reference(Location) Place of service or where product was supplied --></location[x]>
  <quantity><!-- 0..1 Quantity(SimpleQuantity) Count of products or services --></quantity>
  <unitPrice><!-- 0..1 Money Fee, charge or cost per item --></unitPrice>
  <factor value="[decimal]"/><!-- 0..1 Price scaling factor -->
  <</net>
  <</bodySite>
  <</subSite>

  <tax><!-- 0..1 Money Total tax --></tax>
  <net><!-- 0..1 Money Total item cost --></net>
  <bodySite>  <!-- 0..* Anatomical location -->
   <site><!-- 1..* CodeableReference(BodyStructure) Location --></site>
   <subSite><!-- 0..* CodeableConcept Sub-location --></subSite>
  </bodySite>

  <noteNumber value="[positiveInt]"/><!-- 0..* Applicable note numbers -->
  <</adjudication>

  <reviewOutcome><!-- 0..1 Content as for ClaimResponse.item.reviewOutcome Added items adjudication results --></reviewOutcome>
  <adjudication><!-- 0..* Content as for ClaimResponse.item.adjudication Added items adjudication --></adjudication>

  <detail>  <!-- 0..* Insurer added line details -->
   <</productOrService>

   <traceNumber><!-- 0..* Identifier Number for tracking --></traceNumber>
   <revenue><!-- 0..1 CodeableConcept Revenue or cost center code --></revenue>
   <productOrService><!-- 0..1 CodeableConcept Billing, service, product, or drug code --></productOrService>
   <productOrServiceEnd><!-- 0..1 CodeableConcept End of a range of codes --></productOrServiceEnd>

   <modifier><!-- 0..* CodeableConcept Service/Product billing modifiers --></modifier>
   <quantity><!-- 0..1 Quantity(SimpleQuantity) Count of products or services --></quantity>
   <unitPrice><!-- 0..1 Money Fee, charge or cost per item --></unitPrice>
   <factor value="[decimal]"/><!-- 0..1 Price scaling factor -->
   <</net>

   <tax><!-- 0..1 Money Total tax --></tax>
   <net><!-- 0..1 Money Total item cost --></net>

   <noteNumber value="[positiveInt]"/><!-- 0..* Applicable note numbers -->
   <</adjudication>

   <reviewOutcome><!-- 0..1 Content as for ClaimResponse.item.reviewOutcome Added items detail level adjudication results --></reviewOutcome>
   <adjudication><!-- 0..* Content as for ClaimResponse.item.adjudication Added items detail adjudication --></adjudication>

   <subDetail>  <!-- 0..* Insurer added line items -->
    <</productOrService>

    <traceNumber><!-- 0..* Identifier Number for tracking --></traceNumber>
    <revenue><!-- 0..1 CodeableConcept Revenue or cost center code --></revenue>
    <productOrService><!-- 0..1 CodeableConcept Billing, service, product, or drug code --></productOrService>
    <productOrServiceEnd><!-- 0..1 CodeableConcept End of a range of codes --></productOrServiceEnd>

    <modifier><!-- 0..* CodeableConcept Service/Product billing modifiers --></modifier>
    <quantity><!-- 0..1 Quantity(SimpleQuantity) Count of products or services --></quantity>
    <unitPrice><!-- 0..1 Money Fee, charge or cost per item --></unitPrice>
    <factor value="[decimal]"/><!-- 0..1 Price scaling factor -->
    <</net>

    <tax><!-- 0..1 Money Total tax --></tax>
    <net><!-- 0..1 Money Total item cost --></net>

    <noteNumber value="[positiveInt]"/><!-- 0..* Applicable note numbers -->
    <</adjudication>

    <reviewOutcome><!-- 0..1 Content as for ClaimResponse.item.reviewOutcome Added items subdetail level adjudication results --></reviewOutcome>
    <adjudication><!-- 0..* Content as for ClaimResponse.item.adjudication Added items subdetail adjudication --></adjudication>

   </subDetail>
  </detail>
 </addItem>
 <adjudication><!-- 0..* Content as for ClaimResponse.item.adjudication Header-level adjudication --></adjudication>
 <total>  <!-- 0..* Adjudication totals -->
  <category><!-- 1..1 CodeableConcept Type of adjudication information --></category>
  <amount><!-- 1..1 Money Financial total for the category --></amount>
 </total>
 <payment>  <!-- 0..1 Payment Details -->
  <type><!-- 1..1 CodeableConcept Partial or complete payment --></type>
  <adjustment><!-- 0..1 Money Payment adjustment for non-claim issues --></adjustment>
  <adjustmentReason><!-- 0..1 CodeableConcept Explanation for the adjustment --></adjustmentReason>
  <date value="[date]"/><!-- 0..1 Expected date of payment -->
  <amount><!-- 1..1 Money Payable amount after adjustment --></amount>
  <identifier><!-- 0..1 Identifier Business identifier for the payment --></identifier>
 </payment>
 <fundsReserve><!-- 0..1 CodeableConcept Funds reserved status --></fundsReserve>
 <formCode><!-- 0..1 CodeableConcept Printed form identifier --></formCode>
 <form><!-- 0..1 Attachment Printed reference or actual form --></form>
 <processNote>  <!-- 0..* Note concerning adjudication -->
  <number value="[positiveInt]"/><!-- 0..1 Note instance identifier -->
  <

  <type><!-- 0..1 CodeableConcept Note purpose --></type>

  <text value="[string]"/><!-- 1..1 Note explanatory text -->
  <</language>

  <language><!-- 0..1 CodeableConcept Language of the text --></language>

 </processNote>
 <communicationRequest><!-- 0..* Reference(CommunicationRequest) Request for additional information --></communicationRequest>
 <insurance>  <!-- 0..* Patient insurance information -->
  <sequence value="[positiveInt]"/><!-- 1..1 Insurance instance identifier -->
  <focal value="[boolean]"/><!-- 1..1 Coverage to be used for adjudication -->
  <coverage><!-- 1..1 Reference(Coverage) Insurance information --></coverage>
  <businessArrangement value="[string]"/><!-- 0..1 Additional provider contract number -->
  <claimResponse><!-- 0..1 Reference(ClaimResponse) Adjudication results --></claimResponse>
 </insurance>
 <error>  <!-- 0..* Processing errors -->
  <itemSequence value="[positiveInt]"/><!-- 0..1 Item sequence number -->
  <detailSequence value="[positiveInt]"/><!-- 0..1 Detail sequence number -->
  <subDetailSequence value="[positiveInt]"/><!-- 0..1 Subdetail sequence number -->
  <code><!-- 1..1 CodeableConcept Error code detailing processing issues --></code>
  <expression value="[string]"/><!-- 0..* FHIRPath of element(s) related to issue -->

 </error>
</ClaimResponse>

JSON Template 

{doco
  "resourceType" : "ClaimResponse",
  // from Resource: id, meta, implicitRules, and language
  // from DomainResource: text, contained, extension, and modifierExtension
  "identifier" : [{ Identifier }], // Business Identifier for a claim response
  "traceNumber" : [{ Identifier }], // Number for tracking

  "status" : "<code>", // R!  active | cancelled | draft | entered-in-error
  "type" : { CodeableConcept }, // R!  More granular claim type
  "subType" : { CodeableConcept }, // More granular claim type
  "

  "use" : "<code>", // R!  claim | preauthorization | predetermination

  "patient" : { Reference(Patient) }, // R!  The recipient of the products and services
  "created" : "<dateTime>", // R!  Response creation date
  "
  "

  "insurer" : { Reference(Organization) }, // Party responsible for reimbursement
  "requestor" : { Reference(Organization|Practitioner|PractitionerRole) }, // Party responsible for the claim

  "request" : { Reference(Claim) }, // Id of resource triggering adjudication
  "

  "outcome" : "<code>", // R!  queued | complete | error | partial
  "decision" : { CodeableConcept }, // Result of the adjudication

  "disposition" : "<string>", // Disposition Message
  "preAuthRef" : "<string>", // Preauthorization reference
  "preAuthPeriod" : { Period }, // Preauthorization reference effective period
  "event" : [{ // Event information
    "type" : { CodeableConcept }, // R!  Specific event
    // when[x]: Occurance date or period. One of these 2:

    "whenDateTime" : "<dateTime>",
    "whenPeriod" : { Period }
  }],

  "payeeType" : { CodeableConcept }, // Party to be paid any benefits payable
  "encounter" : [{ Reference(Encounter) }], // Encounters associated with the listed treatments
  "diagnosisRelatedGroup" : { CodeableConcept }, // Package billing code

  "item" : [{ // Adjudication for claim line items
    "itemSequence" : "<positiveInt>", // R!  Claim item instance identifier
    "traceNumber" : [{ Identifier }], // Number for tracking

    "noteNumber" : ["<positiveInt>"], // Applicable note numbers
    "

    "reviewOutcome" : { // Adjudication results
      "decision" : { CodeableConcept }, // Result of the adjudication
      "reason" : [{ CodeableConcept }], // Reason for result of the adjudication
      "preAuthRef" : "<string>", // Preauthorization reference
      "preAuthPeriod" : { Period } // Preauthorization reference effective period
    },
    "adjudication" : [{ // Adjudication details

      "category" : { CodeableConcept }, // R!  Type of adjudication information
      "reason" : { CodeableConcept }, // Explanation of adjudication outcome
      "amount" : { Money }, // Monetary amount
      "

      "quantity" : { Quantity } // Non-monetary value

    }],
    "detail" : [{ // Adjudication for claim details
      "detailSequence" : "<positiveInt>", // R!  Claim detail instance identifier
      "traceNumber" : [{ Identifier }], // Number for tracking

      "noteNumber" : ["<positiveInt>"], // Applicable note numbers
      "

      "reviewOutcome" : { Content as for ClaimResponse.item.reviewOutcome }, // Detail level adjudication results
      "adjudication" : [{ Content as for ClaimResponse.item.adjudication }], // Detail level adjudication details

      "subDetail" : [{ // Adjudication for claim sub-details
        "subDetailSequence" : "<positiveInt>", // R!  Claim sub-detail instance identifier
        "traceNumber" : [{ Identifier }], // Number for tracking

        "noteNumber" : ["<positiveInt>"], // Applicable note numbers
        "reviewOutcome" : { Content as for ClaimResponse.item.reviewOutcome }, // Subdetail level adjudication results

        "adjudication" : [{ Content as for ClaimResponse.item.adjudication }] // Subdetail level adjudication details
      }]
    }]
  }],
  "addItem" : [{ // Insurer added line items
    "itemSequence" : ["<positiveInt>"], // Item sequence number
    "detailSequence" : ["<positiveInt>"], // Detail sequence number
    "subdetailSequence" : ["<positiveInt>"], // Subdetail sequence number
    "
    "

    "traceNumber" : [{ Identifier }], // Number for tracking
    "provider" : [{ Reference(Organization|Practitioner|PractitionerRole) }], // Authorized providers
    "revenue" : { CodeableConcept }, // Revenue or cost center code
    "productOrService" : { CodeableConcept }, // Billing, service, product, or drug code
    "productOrServiceEnd" : { CodeableConcept }, // End of a range of codes
    "request" : [{ Reference(DeviceRequest|MedicationRequest|NutritionOrder|
    ServiceRequest|SupplyRequest|VisionPrescription) }], // Request or Referral for Service
    "modifier" : [{ CodeableConcept }], // Service/Product billing modifiers
    "programCode" : [{ CodeableConcept }], // Program the product or service is provided under
    // serviced[x]: Date or dates of service or product delivery. One of these 2:
    "servicedDate" : "<date>",
    "servicedPeriod" : { Period },
    // location[x]: Place of service or where product was supplied. One of these 3:
    "locationCodeableConcept" : { CodeableConcept },
    "locationAddress" : { Address },
    "locationReference" : { Reference(Location) },
    "quantity" : { Quantity(SimpleQuantity) }, // Count of products or services
    "unitPrice" : { Money }, // Fee, charge or cost per item
    "factor" : <decimal>, // Price scaling factor
    "
    "
    "

    "tax" : { Money }, // Total tax
    "net" : { Money }, // Total item cost
    "bodySite" : [{ // Anatomical location
      "site" : [{ CodeableReference(BodyStructure) }], // R!  Location
      "subSite" : [{ CodeableConcept }] // Sub-location
    }],

    "noteNumber" : ["<positiveInt>"], // Applicable note numbers
    "

    "reviewOutcome" : { Content as for ClaimResponse.item.reviewOutcome }, // Added items adjudication results
    "adjudication" : [{ Content as for ClaimResponse.item.adjudication }], // Added items adjudication

    "detail" : [{ // Insurer added line details
      "

      "traceNumber" : [{ Identifier }], // Number for tracking
      "revenue" : { CodeableConcept }, // Revenue or cost center code
      "productOrService" : { CodeableConcept }, // Billing, service, product, or drug code
      "productOrServiceEnd" : { CodeableConcept }, // End of a range of codes

      "modifier" : [{ CodeableConcept }], // Service/Product billing modifiers
      "quantity" : { Quantity(SimpleQuantity) }, // Count of products or services
      "unitPrice" : { Money }, // Fee, charge or cost per item
      "factor" : <decimal>, // Price scaling factor
      "

      "tax" : { Money }, // Total tax
      "net" : { Money }, // Total item cost

      "noteNumber" : ["<positiveInt>"], // Applicable note numbers
      "

      "reviewOutcome" : { Content as for ClaimResponse.item.reviewOutcome }, // Added items detail level adjudication results
      "adjudication" : [{ Content as for ClaimResponse.item.adjudication }], // Added items detail adjudication

      "subDetail" : [{ // Insurer added line items
        "

        "traceNumber" : [{ Identifier }], // Number for tracking
        "revenue" : { CodeableConcept }, // Revenue or cost center code
        "productOrService" : { CodeableConcept }, // Billing, service, product, or drug code
        "productOrServiceEnd" : { CodeableConcept }, // End of a range of codes

        "modifier" : [{ CodeableConcept }], // Service/Product billing modifiers
        "quantity" : { Quantity(SimpleQuantity) }, // Count of products or services
        "unitPrice" : { Money }, // Fee, charge or cost per item
        "factor" : <decimal>, // Price scaling factor
        "

        "tax" : { Money }, // Total tax
        "net" : { Money }, // Total item cost

        "noteNumber" : ["<positiveInt>"], // Applicable note numbers
        "

        "reviewOutcome" : { Content as for ClaimResponse.item.reviewOutcome }, // Added items subdetail level adjudication results
        "adjudication" : [{ Content as for ClaimResponse.item.adjudication }] // Added items subdetail adjudication

      }]
    }]
  }],
  "adjudication" : [{ Content as for ClaimResponse.item.adjudication }], // Header-level adjudication
  "total" : [{ // Adjudication totals
    "category" : { CodeableConcept }, // R!  Type of adjudication information
    "amount" : { Money } // R!  Financial total for the category
  }],
  "payment" : { // Payment Details
    "type" : { CodeableConcept }, // R!  Partial or complete payment
    "adjustment" : { Money }, // Payment adjustment for non-claim issues
    "adjustmentReason" : { CodeableConcept }, // Explanation for the adjustment
    "date" : "<date>", // Expected date of payment
    "amount" : { Money }, // R!  Payable amount after adjustment
    "identifier" : { Identifier } // Business identifier for the payment
  },
  "fundsReserve" : { CodeableConcept }, // Funds reserved status
  "formCode" : { CodeableConcept }, // Printed form identifier
  "form" : { Attachment }, // Printed reference or actual form
  "processNote" : [{ // Note concerning adjudication
    "number" : "<positiveInt>", // Note instance identifier
    "

    "type" : { CodeableConcept }, // Note purpose

    "text" : "<string>", // R!  Note explanatory text
    "

    "language" : { CodeableConcept } // Language of the text

  }],
  "communicationRequest" : [{ Reference(CommunicationRequest) }], // Request for additional information
  "insurance" : [{ // Patient insurance information
    "sequence" : "<positiveInt>", // R!  Insurance instance identifier
    "focal" : <boolean>, // R!  Coverage to be used for adjudication
    "coverage" : { Reference(Coverage) }, // R!  Insurance information
    "businessArrangement" : "<string>", // Additional provider contract number
    "claimResponse" : { Reference(ClaimResponse) } // Adjudication results
  }],
  "error" : [{ // Processing errors
    "itemSequence" : "<positiveInt>", // Item sequence number
    "detailSequence" : "<positiveInt>", // Detail sequence number
    "subDetailSequence" : "<positiveInt>", // Subdetail sequence number
    "

    "code" : { CodeableConcept }, // R!  Error code detailing processing issues
    "expression" : ["<string>"] // FHIRPath of element(s) related to issue

  }]
}

Turtle Template 

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


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

  # from Resource: .id, .meta, .implicitRules, and .language
  # from DomainResource: .text, .contained, .extension, and .modifierExtension
  fhir:
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    ], ...;
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      ], ...;
    ], ...;
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    # . One of these 2
      fhir: ]
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    # . One of these 3
      fhir: ]
      fhir: ]
      fhir:) ]
    fhir:
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      ], ...;
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  ];
  fhir:
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  ], ...;
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  ], ...;
  fhir:
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  ], ...;

  fhir:identifier  ( [ Identifier ] ... ) ; # 0..* Business Identifier for a claim response
  fhir:traceNumber  ( [ Identifier ] ... ) ; # 0..* Number for tracking
  fhir:status [ code ] ; # 1..1 active | cancelled | draft | entered-in-error
  fhir:type [ CodeableConcept ] ; # 1..1 More granular claim type
  fhir:subType [ CodeableConcept ] ; # 0..1 More granular claim type
  fhir:use [ code ] ; # 1..1 claim | preauthorization | predetermination
  fhir:patient [ Reference(Patient) ] ; # 1..1 The recipient of the products and services
  fhir:created [ dateTime ] ; # 1..1 Response creation date
  fhir:insurer [ Reference(Organization) ] ; # 0..1 Party responsible for reimbursement
  fhir:requestor [ Reference(Organization|Practitioner|PractitionerRole) ] ; # 0..1 Party responsible for the claim
  fhir:request [ Reference(Claim) ] ; # 0..1 Id of resource triggering adjudication
  fhir:outcome [ code ] ; # 1..1 queued | complete | error | partial
  fhir:decision [ CodeableConcept ] ; # 0..1 Result of the adjudication
  fhir:disposition [ string ] ; # 0..1 Disposition Message
  fhir:preAuthRef [ string ] ; # 0..1 Preauthorization reference
  fhir:preAuthPeriod [ Period ] ; # 0..1 Preauthorization reference effective period
  fhir:event ( [ # 0..* Event information
    fhir:type [ CodeableConcept ] ; # 1..1 Specific event
    # when[x] : 1..1 Occurance date or period. One of these 2
      fhir:when [  a fhir:dateTime ; dateTime ]
      fhir:when [  a fhir:Period ; Period ]
  ] ... ) ;
  fhir:payeeType [ CodeableConcept ] ; # 0..1 Party to be paid any benefits payable
  fhir:encounter  ( [ Reference(Encounter) ] ... ) ; # 0..* Encounters associated with the listed treatments
  fhir:diagnosisRelatedGroup [ CodeableConcept ] ; # 0..1 Package billing code
  fhir:item ( [ # 0..* Adjudication for claim line items
    fhir:itemSequence [ positiveInt ] ; # 1..1 Claim item instance identifier
    fhir:traceNumber  ( [ Identifier ] ... ) ; # 0..* Number for tracking
    fhir:noteNumber  ( [ positiveInt ] ... ) ; # 0..* Applicable note numbers
    fhir:reviewOutcome [ # 0..1 Adjudication results
      fhir:decision [ CodeableConcept ] ; # 0..1 Result of the adjudication
      fhir:reason  ( [ CodeableConcept ] ... ) ; # 0..* Reason for result of the adjudication
      fhir:preAuthRef [ string ] ; # 0..1 Preauthorization reference
      fhir:preAuthPeriod [ Period ] ; # 0..1 Preauthorization reference effective period
    ] ;
    fhir:adjudication ( [ # 0..* Adjudication details
      fhir:category [ CodeableConcept ] ; # 1..1 Type of adjudication information
      fhir:reason [ CodeableConcept ] ; # 0..1 Explanation of adjudication outcome
      fhir:amount [ Money ] ; # 0..1 Monetary amount
      fhir:quantity [ Quantity ] ; # 0..1 Non-monetary value
    ] ... ) ;
    fhir:detail ( [ # 0..* Adjudication for claim details
      fhir:detailSequence [ positiveInt ] ; # 1..1 Claim detail instance identifier
      fhir:traceNumber  ( [ Identifier ] ... ) ; # 0..* Number for tracking
      fhir:noteNumber  ( [ positiveInt ] ... ) ; # 0..* Applicable note numbers
      fhir:reviewOutcome [ See ClaimResponse.item.reviewOutcome ] ; # 0..1 Detail level adjudication results
      fhir:adjudication  ( [ See ClaimResponse.item.adjudication ] ... ) ; # 0..* Detail level adjudication details
      fhir:subDetail ( [ # 0..* Adjudication for claim sub-details
        fhir:subDetailSequence [ positiveInt ] ; # 1..1 Claim sub-detail instance identifier
        fhir:traceNumber  ( [ Identifier ] ... ) ; # 0..* Number for tracking
        fhir:noteNumber  ( [ positiveInt ] ... ) ; # 0..* Applicable note numbers
        fhir:reviewOutcome [ See ClaimResponse.item.reviewOutcome ] ; # 0..1 Subdetail level adjudication results
        fhir:adjudication  ( [ See ClaimResponse.item.adjudication ] ... ) ; # 0..* Subdetail level adjudication details
      ] ... ) ;
    ] ... ) ;
  ] ... ) ;
  fhir:addItem ( [ # 0..* Insurer added line items
    fhir:itemSequence  ( [ positiveInt ] ... ) ; # 0..* Item sequence number
    fhir:detailSequence  ( [ positiveInt ] ... ) ; # 0..* Detail sequence number
    fhir:subdetailSequence  ( [ positiveInt ] ... ) ; # 0..* Subdetail sequence number
    fhir:traceNumber  ( [ Identifier ] ... ) ; # 0..* Number for tracking
    fhir:provider  ( [ Reference(Organization|Practitioner|PractitionerRole) ] ... ) ; # 0..* Authorized providers
    fhir:revenue [ CodeableConcept ] ; # 0..1 Revenue or cost center code
    fhir:productOrService [ CodeableConcept ] ; # 0..1 Billing, service, product, or drug code
    fhir:productOrServiceEnd [ CodeableConcept ] ; # 0..1 End of a range of codes
    fhir:request  ( [ Reference(DeviceRequest|MedicationRequest|NutritionOrder|ServiceRequest|SupplyRequest|
  VisionPrescription) ] ... ) ; # 0..* Request or Referral for Service

    fhir:modifier  ( [ CodeableConcept ] ... ) ; # 0..* Service/Product billing modifiers
    fhir:programCode  ( [ CodeableConcept ] ... ) ; # 0..* Program the product or service is provided under
    # serviced[x] : 0..1 Date or dates of service or product delivery. One of these 2
      fhir:serviced [  a fhir:date ; date ]
      fhir:serviced [  a fhir:Period ; Period ]
    # location[x] : 0..1 Place of service or where product was supplied. One of these 3
      fhir:location [  a fhir:CodeableConcept ; CodeableConcept ]
      fhir:location [  a fhir:Address ; Address ]
      fhir:location [  a fhir:Reference ; Reference(Location) ]
    fhir:quantity [ Quantity(SimpleQuantity) ] ; # 0..1 Count of products or services
    fhir:unitPrice [ Money ] ; # 0..1 Fee, charge or cost per item
    fhir:factor [ decimal ] ; # 0..1 Price scaling factor
    fhir:tax [ Money ] ; # 0..1 Total tax
    fhir:net [ Money ] ; # 0..1 Total item cost
    fhir:bodySite ( [ # 0..* Anatomical location
      fhir:site  ( [ CodeableReference(BodyStructure) ] ... ) ; # 1..* Location
      fhir:subSite  ( [ CodeableConcept ] ... ) ; # 0..* Sub-location
    ] ... ) ;
    fhir:noteNumber  ( [ positiveInt ] ... ) ; # 0..* Applicable note numbers
    fhir:reviewOutcome [ See ClaimResponse.item.reviewOutcome ] ; # 0..1 Added items adjudication results
    fhir:adjudication  ( [ See ClaimResponse.item.adjudication ] ... ) ; # 0..* Added items adjudication
    fhir:detail ( [ # 0..* Insurer added line details
      fhir:traceNumber  ( [ Identifier ] ... ) ; # 0..* Number for tracking
      fhir:revenue [ CodeableConcept ] ; # 0..1 Revenue or cost center code
      fhir:productOrService [ CodeableConcept ] ; # 0..1 Billing, service, product, or drug code
      fhir:productOrServiceEnd [ CodeableConcept ] ; # 0..1 End of a range of codes
      fhir:modifier  ( [ CodeableConcept ] ... ) ; # 0..* Service/Product billing modifiers
      fhir:quantity [ Quantity(SimpleQuantity) ] ; # 0..1 Count of products or services
      fhir:unitPrice [ Money ] ; # 0..1 Fee, charge or cost per item
      fhir:factor [ decimal ] ; # 0..1 Price scaling factor
      fhir:tax [ Money ] ; # 0..1 Total tax
      fhir:net [ Money ] ; # 0..1 Total item cost
      fhir:noteNumber  ( [ positiveInt ] ... ) ; # 0..* Applicable note numbers
      fhir:reviewOutcome [ See ClaimResponse.item.reviewOutcome ] ; # 0..1 Added items detail level adjudication results
      fhir:adjudication  ( [ See ClaimResponse.item.adjudication ] ... ) ; # 0..* Added items detail adjudication
      fhir:subDetail ( [ # 0..* Insurer added line items
        fhir:traceNumber  ( [ Identifier ] ... ) ; # 0..* Number for tracking
        fhir:revenue [ CodeableConcept ] ; # 0..1 Revenue or cost center code
        fhir:productOrService [ CodeableConcept ] ; # 0..1 Billing, service, product, or drug code
        fhir:productOrServiceEnd [ CodeableConcept ] ; # 0..1 End of a range of codes
        fhir:modifier  ( [ CodeableConcept ] ... ) ; # 0..* Service/Product billing modifiers
        fhir:quantity [ Quantity(SimpleQuantity) ] ; # 0..1 Count of products or services
        fhir:unitPrice [ Money ] ; # 0..1 Fee, charge or cost per item
        fhir:factor [ decimal ] ; # 0..1 Price scaling factor
        fhir:tax [ Money ] ; # 0..1 Total tax
        fhir:net [ Money ] ; # 0..1 Total item cost
        fhir:noteNumber  ( [ positiveInt ] ... ) ; # 0..* Applicable note numbers
        fhir:reviewOutcome [ See ClaimResponse.item.reviewOutcome ] ; # 0..1 Added items subdetail level adjudication results
        fhir:adjudication  ( [ See ClaimResponse.item.adjudication ] ... ) ; # 0..* Added items subdetail adjudication
      ] ... ) ;
    ] ... ) ;
  ] ... ) ;
  fhir:adjudication  ( [ See ClaimResponse.item.adjudication ] ... ) ; # 0..* Header-level adjudication
  fhir:total ( [ # 0..* Adjudication totals
    fhir:category [ CodeableConcept ] ; # 1..1 Type of adjudication information
    fhir:amount [ Money ] ; # 1..1 Financial total for the category
  ] ... ) ;
  fhir:payment [ # 0..1 Payment Details
    fhir:type [ CodeableConcept ] ; # 1..1 Partial or complete payment
    fhir:adjustment [ Money ] ; # 0..1 Payment adjustment for non-claim issues
    fhir:adjustmentReason [ CodeableConcept ] ; # 0..1 Explanation for the adjustment
    fhir:date [ date ] ; # 0..1 Expected date of payment
    fhir:amount [ Money ] ; # 1..1 Payable amount after adjustment
    fhir:identifier [ Identifier ] ; # 0..1 Business identifier for the payment
  ] ;
  fhir:fundsReserve [ CodeableConcept ] ; # 0..1 Funds reserved status
  fhir:formCode [ CodeableConcept ] ; # 0..1 Printed form identifier
  fhir:form [ Attachment ] ; # 0..1 Printed reference or actual form
  fhir:processNote ( [ # 0..* Note concerning adjudication
    fhir:number [ positiveInt ] ; # 0..1 Note instance identifier
    fhir:type [ CodeableConcept ] ; # 0..1 Note purpose
    fhir:text [ string ] ; # 1..1 Note explanatory text
    fhir:language [ CodeableConcept ] ; # 0..1 Language of the text
  ] ... ) ;
  fhir:communicationRequest  ( [ Reference(CommunicationRequest) ] ... ) ; # 0..* Request for additional information
  fhir:insurance ( [ # 0..* Patient insurance information
    fhir:sequence [ positiveInt ] ; # 1..1 Insurance instance identifier
    fhir:focal [ boolean ] ; # 1..1 Coverage to be used for adjudication
    fhir:coverage [ Reference(Coverage) ] ; # 1..1 Insurance information
    fhir:businessArrangement [ string ] ; # 0..1 Additional provider contract number
    fhir:claimResponse [ Reference(ClaimResponse) ] ; # 0..1 Adjudication results
  ] ... ) ;
  fhir:error ( [ # 0..* Processing errors
    fhir:itemSequence [ positiveInt ] ; # 0..1 Item sequence number
    fhir:detailSequence [ positiveInt ] ; # 0..1 Detail sequence number
    fhir:subDetailSequence [ positiveInt ] ; # 0..1 Subdetail sequence number
    fhir:code [ CodeableConcept ] ; # 1..1 Error code detailing processing issues
    fhir:expression  ( [ string ] ... ) ; # 0..* FHIRPath of element(s) related to issue
  ] ... ) ;

]

Changes since Release 3 from both R4 and R4B

ClaimResponse.patient Min Cardinality changed from 0 to 1
ClaimResponse
ClaimResponse.traceNumber
  • Added Element
ClaimResponse.status ClaimResponse.insurer
  • Min Cardinality changed from 0 to 1 to 0
ClaimResponse.outcome
  • Change value set from http://hl7.org/fhir/ValueSet/fm-status http://hl7.org/fhir/ValueSet/remittance-outcome|4.0.0 to http://hl7.org/fhir/ValueSet/fm-status|4.0.1 Claim Processing Codes
ClaimResponse.type ClaimResponse.decision
  • Added Mandatory Element
ClaimResponse.subType ClaimResponse.event
  • Added Element
ClaimResponse.use ClaimResponse.event.type
  • Added Mandatory Element
ClaimResponse.created ClaimResponse.event.when[x]
  • Min Cardinality changed from 0 to 1 Added Mandatory Element
ClaimResponse.insurer ClaimResponse.encounter
  • Min Cardinality changed from 0 to 1 Added Element
ClaimResponse.requestor ClaimResponse.diagnosisRelatedGroup
  • Renamed from requestProvider to requestor Type Reference: Added Target Types PractitionerRole, Organization Element
ClaimResponse.outcome ClaimResponse.item.traceNumber
  • Min Cardinality changed from 0 to 1 Type changed from CodeableConcept to code Add Binding http://hl7.org/fhir/ValueSet/remittance-outcome|4.0.1 (required) Added Element
ClaimResponse.preAuthRef ClaimResponse.item.reviewOutcome
  • Moved from ClaimResponse.insurance to ClaimResponse Max Cardinality changed from * to 1 Added Element
ClaimResponse.preAuthPeriod ClaimResponse.item.reviewOutcome.decision
  • Added Element
ClaimResponse.item.itemSequence ClaimResponse.item.reviewOutcome.reason
  • Renamed from sequenceLinkId to itemSequence Added Element
ClaimResponse.item.adjudication ClaimResponse.item.reviewOutcome.preAuthRef
  • Min Cardinality changed from 0 to 1 Added Element
ClaimResponse.item.detail.detailSequence ClaimResponse.item.reviewOutcome.preAuthPeriod
  • Renamed from sequenceLinkId to detailSequence Added Element
ClaimResponse.item.detail.adjudication ClaimResponse.item.adjudication
  • Min Cardinality changed from 0 to 1 ClaimResponse.item.detail.subDetail.subDetailSequence Renamed from sequenceLinkId to subDetailSequence ClaimResponse.addItem.itemSequence Renamed from sequenceLinkId to itemSequence 0
ClaimResponse.addItem.detailSequence ClaimResponse.item.adjudication.quantity
  • Added Element
ClaimResponse.addItem.subdetailSequence ClaimResponse.item.detail.traceNumber
  • Added Element
ClaimResponse.addItem.provider ClaimResponse.item.detail.reviewOutcome
  • Added Element
ClaimResponse.addItem.productOrService ClaimResponse.item.detail.adjudication
    Renamed from service to productOrService
  • Min Cardinality changed from 0 to 1 to 0
ClaimResponse.addItem.programCode Added Element ClaimResponse.addItem.serviced[x] ClaimResponse.item.detail.subDetail.traceNumber
  • Added Element
ClaimResponse.addItem.location[x] ClaimResponse.item.detail.subDetail.reviewOutcome
  • Added Element
ClaimResponse.addItem.quantity ClaimResponse.addItem.traceNumber
  • Added Element
ClaimResponse.addItem.unitPrice ClaimResponse.addItem.revenue
  • Added Element
ClaimResponse.addItem.factor ClaimResponse.addItem.productOrService
  • Added Element Min Cardinality changed from 1 to 0
ClaimResponse.addItem.net ClaimResponse.addItem.productOrServiceEnd
  • Added Element
ClaimResponse.addItem.bodySite ClaimResponse.addItem.request
  • Added Element
ClaimResponse.addItem.subSite ClaimResponse.addItem.tax
  • Added Element
ClaimResponse.addItem.adjudication ClaimResponse.addItem.bodySite
  • Min Max Cardinality changed from 0 to 1 ClaimResponse.addItem.detail.productOrService Renamed from service to productOrService *
  • Min Cardinality Type changed from 0 CodeableConcept to 1 ClaimResponse.addItem.detail.quantity Added Element BackboneElement
ClaimResponse.addItem.detail.unitPrice ClaimResponse.addItem.bodySite.site
  • Added Mandatory Element
ClaimResponse.addItem.detail.factor ClaimResponse.addItem.bodySite.subSite
  • Added Element
ClaimResponse.addItem.detail.net ClaimResponse.addItem.reviewOutcome
  • Added Element
ClaimResponse.addItem.detail.adjudication ClaimResponse.addItem.adjudication
  • Min Cardinality changed from 0 to 1 to 0
ClaimResponse.addItem.detail.subDetail ClaimResponse.addItem.detail.traceNumber
  • Added Element
ClaimResponse.addItem.detail.subDetail.productOrService ClaimResponse.addItem.detail.revenue
  • Added Mandatory Element
ClaimResponse.addItem.detail.subDetail.modifier ClaimResponse.addItem.detail.productOrService
  • Added Element Min Cardinality changed from 1 to 0
ClaimResponse.addItem.detail.subDetail.quantity ClaimResponse.addItem.detail.productOrServiceEnd
  • Added Element
ClaimResponse.addItem.detail.subDetail.unitPrice ClaimResponse.addItem.detail.tax
  • Added Element
ClaimResponse.addItem.detail.subDetail.factor ClaimResponse.addItem.detail.reviewOutcome
  • Added Element
ClaimResponse.addItem.detail.subDetail.net ClaimResponse.addItem.detail.adjudication
  • Added Element Min Cardinality changed from 1 to 0
ClaimResponse.addItem.detail.subDetail.noteNumber ClaimResponse.addItem.detail.subDetail.traceNumber
  • Added Element
ClaimResponse.addItem.detail.subDetail.adjudication ClaimResponse.addItem.detail.subDetail.revenue
  • Added Mandatory Element
ClaimResponse.adjudication ClaimResponse.addItem.detail.subDetail.productOrService
  • Added Element Min Cardinality changed from 1 to 0
ClaimResponse.total ClaimResponse.addItem.detail.subDetail.productOrServiceEnd
  • Added Element
ClaimResponse.total.category ClaimResponse.addItem.detail.subDetail.tax
  • Added Mandatory Element
ClaimResponse.total.amount ClaimResponse.addItem.detail.subDetail.reviewOutcome
  • Added Mandatory Element
ClaimResponse.payment.type ClaimResponse.addItem.detail.subDetail.adjudication
  • Min Cardinality changed from 0 to 1 ClaimResponse.payment.amount Min Cardinality changed from 0 to 1 ClaimResponse.fundsReserve Renamed from reserved to fundsReserve Type changed from Coding to CodeableConcept ClaimResponse.formCode Added Element ClaimResponse.form Type changed from CodeableConcept to Attachment 0
ClaimResponse.processNote.type
  • Type changed from CodeableConcept to code Change value set from http://hl7.org/fhir/ValueSet/note-type to http://hl7.org/fhir/ValueSet/note-type|4.0.1 CodeableConcept
    • ClaimResponse.processNote.text
  • Min Cardinality changed Change binding strength from 0 required to 1 extensible
ClaimResponse.processNote.language
  • Change binding strength from extensible to preferred ClaimResponse.error.itemSequence Renamed from sequenceLinkId to itemSequence required
    • ClaimResponse.error.detailSequence
  • Renamed Change value set from detailSequenceLinkId Common Languages to detailSequence All Languages
    • ClaimResponse.error.subDetailSequence
  • Renamed Change max value set from subdetailSequenceLinkId All Languages to subDetailSequence ClaimResponse.requestOrganization deleted ClaimResponse.addItem.revenue deleted ClaimResponse.addItem.category deleted ClaimResponse.addItem.fee deleted ClaimResponse.addItem.detail.revenue deleted ClaimResponse.addItem.detail.category deleted ClaimResponse.addItem.detail.fee deleted none
ClaimResponse.totalCost ClaimResponse.error.expression
  • deleted Added Element
ClaimResponse.unallocDeductable ClaimResponse.item.adjudication.value
  • deleted Deleted
ClaimResponse.totalBenefit ClaimResponse.addItem.subSite
  • deleted Deleted

See the Full Difference for further information

This analysis is available for R4 as XML or JSON and for R4B as XML or JSON .

See R3 <--> R4 <--> R5 Conversion Maps (status = 1 test that all execute ok. 1 fail round-trip testing and 1 r3 resources are invalid (0 errors). ) See Conversions Summary .)

 

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

13.7.3.1 13.7.4.1 Terminology Bindings

ClaimResponse.payeeType ClaimResponse.item.adjudication.category ClaimResponse.total.category ClaimResponse.payment.type A human language.
Path Definition ValueSet Type Reference Documentation
ClaimResponse.status A code specifying the state of the resource instance. FinancialResourceStatusCodes Required FinancialResourceStatusCodes

This value set includes Status codes.

ClaimResponse.type The type or discipline-style of the claim. ClaimTypeCodes Extensible ClaimTypeCodes

This value set includes Claim Type codes.

ClaimResponse.subType A more granular claim typecode. ExampleClaimSubTypeCodes Example ExampleClaimSubTypeCodes

This value set includes sample Claim SubType codes which are used to distinguish the claim types for example within type institutional there may be subtypes for emergency services, bed stay and transportation.

ClaimResponse.use Claim, preauthorization, predetermination. Use Required Use

The purpose of the Claim: predetermination, preauthorization, claim.

ClaimResponse.outcome The result of the claim processing. ClaimProcessingCodes (a valid code from Claim Processing Outcome Codes ) Required ClaimProcessingCodes

This value set includes Claim Processing Outcome codes.

ClaimResponse.decision ClaimAdjudicationDecisionsCodes (a valid code from Claim Adjudication Decision Codes ) Example

This value set includes Claim Adjudication Decision codes.

ClaimResponse.event.type A DatesTypeCodes (a valid code for the party to be reimbursed. from Dates Event Type Codes ) Example

This value set includes sample Dates Type codes.

ClaimResponse.payeeType Claim ClaimPayeeTypeCodes Example

This value set includes sample Payee Type Codes codes.

ClaimResponse.diagnosisRelatedGroup ExampleDiagnosisRelatedGroupCodes Example

This value set includes example Diagnosis Related Group codes.

ClaimResponse.item.reviewOutcome.decision The adjudication ClaimAdjudicationDecisionsCodes (a valid code from Claim Adjudication Decision Codes ) Example

This value set includes Claim Adjudication Decision codes.

ClaimResponse.item.reviewOutcome.reason ClaimAdjudicationDecisionReasonCodes Example

This value set includes example Claim Adjudication Decision Reason codes.

ClaimResponse.item.adjudication.category AdjudicationValueCodes Example

This value set includes a smattering of Adjudication Value codes which includes codes to indicate the amounts eligible under the plan, the amount of benefit, copays etc.

ClaimResponse.item.adjudication.reason The adjudication reason codes. AdjudicationReasonCodes Example AdjudicationReasonCodes

This value set includes smattering of Adjudication Reason codes.

ClaimResponse.addItem.revenue ExampleRevenueCenterCodes Example

This value set includes sample Revenue Center codes.

ClaimResponse.addItem.productOrService ClaimResponse.addItem.detail.productOrService ClaimResponse.addItem.detail.subDetail.productOrService Allowable service and product codes. USCLSCodes Example

This value set includes a smattering of USCLS codes.

ClaimResponse.addItem.productOrServiceEnd USCLSCodes Example

This value set includes a smattering of USCLS codes.

ClaimResponse.addItem.modifier ClaimResponse.addItem.detail.modifier ClaimResponse.addItem.detail.subDetail.modifier Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen. ModifierTypeCodes Example ModifierTypeCodes

This value set includes sample Modifier type codes.

ClaimResponse.addItem.programCode Program specific reason codes. ExampleProgramReasonCodes Example ExampleProgramReasonCodes

This value set includes sample Program Reason Span codes.

ClaimResponse.addItem.location[x] Place of service: pharmacy, school, prison, etc. ExampleServicePlaceCodes Example ExampleServicePlaceCodes

This value set includes a smattering of Service Place codes.

ClaimResponse.addItem.bodySite ClaimResponse.addItem.bodySite.site The code for the teeth, quadrant, sextant and arch. OralSiteCodes Example OralSiteCodes

This value set includes a smattering of FDI oral site codes.

ClaimResponse.addItem.subSite ClaimResponse.addItem.bodySite.subSite The code for the SurfaceCodes Example

This value set includes a smattering of FDI tooth surface and surface combinations. codes.

ClaimResponse.addItem.detail.revenue ExampleRevenueCenterCodes Example SurfaceCodes

This value set includes sample Revenue Center codes.

ClaimResponse.addItem.detail.productOrService USCLSCodes Example

This value set includes a smattering of USCLS codes.

ClaimResponse.addItem.detail.productOrServiceEnd The USCLSCodes Example

This value set includes a smattering of USCLS codes.

ClaimResponse.addItem.detail.modifier ModifierTypeCodes Example

This value set includes sample Modifier type (partial, complete) codes.

ClaimResponse.addItem.detail.subDetail.revenue ExampleRevenueCenterCodes Example

This value set includes sample Revenue Center codes.

ClaimResponse.addItem.detail.subDetail.productOrService USCLSCodes Example

This value set includes a smattering of the payment. USCLS codes.

ClaimResponse.addItem.detail.subDetail.productOrServiceEnd USCLSCodes Example

This value set includes a smattering of USCLS codes.

ClaimResponse.addItem.detail.subDetail.modifier ModifierTypeCodes Example

This value set includes sample Modifier type codes.

ClaimResponse.total.category AdjudicationValueCodes Example

This value set includes a smattering of Adjudication Value codes which includes codes to indicate the amounts eligible under the plan, the amount of benefit, copays etc.

ClaimResponse.payment.type ExamplePaymentTypeCodes Example

This value set includes example Payment Type codes.

ClaimResponse.payment.adjustmentReason Payment Adjustment reason codes. PaymentAdjustmentReasonCodes Example PaymentAdjustmentReasonCodes

This value set includes smattering of Payment Adjustment Reason codes.

ClaimResponse.fundsReserve For whom funds are to be reserved: (Patient, Provider, None). FundsReservationCodes Example Funds Reservation Codes

This value set includes sample funds reservation type codes.

ClaimResponse.formCode The forms codes. FormCodes Example Form Codes

This value set includes a sample set of Forms codes.

ClaimResponse.processNote.type The presentation types of notes. NoteType Required Extensible NoteType

The presentation types of notes.

ClaimResponse.processNote.language Preferred , but limited to AllLanguages (a valid code from Tags for the Identification of Languages icon ) Required

This value set includes all possible codes from BCP-47 (see http://tools.ietf.org/html/bcp47)

  CommonLanguages Common Languages starter
ClaimResponse.error.code The adjudication error codes. AdjudicationErrorCodes Example Adjudication Error Codes

This value set includes a smattering of adjudication codes.

13.7.5 Additional Information

The information presented in different backbone elements, such as .supportingInfo or .adjudication, has a different context based on the .category code presented in each, for example, adjudication occurrence may represent an amount paid by the patient while another may represent the amount paid to the provider.

Additionally, there are several places in the resource which point to other sections of the resource via the use of a .sequence number in the referred-to element and an . element Sequence in the referring element. Sequence numbers appear in such element as .careTeam referred to by .careTeamSequence,.diagnosis referred to by .diagnosisSequence,.procedure referred to by .procedureSequence,.supportingInfo referred to by .informationSequence and .item referred to by .itemSequence.

The .noteNumber element, which appears at the .item,.detail and .subDetail levels in the .item and .addItem structures, contains a list of numbers which match the value of the .number element in the .processNote structure. The process notes are indivdual chunks of text describing a situation associated with insurer explanation of adjudication results. Rather than repeating the same text in the adjudication of line item or detail, the insurer can provide the text once in the .processNote structure then include the associated number value in the list of .noteNumber s for each of the appropriate line items or details.

13.7.4 13.7.6 Search Parameters

Search parameters for this resource. See also the full list of search parameters for this resource , and check the Extensions registry for search parameters on extensions related to this resource. The common parameters also apply. See Searching for more information about searching in REST, messaging, and services.

Name Type Description Expression In Common
created date The creation date ClaimResponse.created
disposition string The contents of the disposition message ClaimResponse.disposition
identifier token The identity of the ClaimResponse ClaimResponse.identifier 65 Resources
insurer reference The organization which generated this resource ClaimResponse.insurer
( Organization )
outcome token The processing outcome ClaimResponse.outcome
patient reference The subject of care ClaimResponse.patient
( Patient ) 		66 Resources
payment-date date The expected payment date ClaimResponse.payment.date
request reference The claim reference ClaimResponse.request
( Claim )
requestor reference The Provider of the claim ClaimResponse.requestor
( Practitioner , Organization , PractitionerRole )
status token The status of the ClaimResponse ClaimResponse.status
use token The type of claim ClaimResponse.use