DSTU2 FHIR Release 3 (STU)

This page is part of the FHIR Specification (v1.0.2: DSTU (v3.0.2: STU 2). 3). The current version which supercedes this version is 5.0.0 . For a full list of available versions, see the Directory of published versions . Page versions: R5 R4B R4 R3 R2 R3 R2

7.2 13.7 Resource ClaimResponse - Content

Financial Management Work Group Maturity Level : 0 2   Trial Use Compartments : Not linked to any defined compartments Patient , Practitioner

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

7.2.1 13.7.1 Scope and Usage

The ClaimResponse resource provides application level error or application level adjudication results which are the result of processing a submitted disciplineClaim Claim resource where that Claim may be which is the functional corollary of a Claim, Pre-Determination or a Pre-Authorization.

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

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

Todo

This resource is referenced by claim Claim and ExplanationOfBenefit

7.2.2 13.7.2 Resource Content

Structure

Σ Σ Resource version Σ Coding Original version Σ Σ Insurer Σ Σ Σ Σ Σ Σ Σ Σ Σ Σ Σ Σ Σ Detail adjudication Σ Coding Adjudication category such as co-pay, eligible, benefit, etc. Σ Monetary amount Σ Non-monetary value Σ Subdetail line items Σ positiveInt Service instance Σ Subdetail adjudication Σ Adjudication category such as co-pay, eligible, benefit, etc. Σ Monetary amount Σ Non-monetary value addItem Σ Σ Group, Service or Product Σ Σ Σ BackboneElement Σ Adjudication category such as co-pay, eligible, benefit, etc. Σ Monetary amount Σ Non-monetary value detail Σ Σ Professional fee or Product charge adjudication Added items detail adjudication Σ Adjudication category such as co-pay, eligible, benefit, etc. Adjudication Codes ( Extensible ) Σ Monetary amount Σ decimal Non-monetary value Σ Σ Σ Σ Σ Σ Σ Σ Σ Reason Σ Σ Payment Σ Payment identifier Σ Σ Σ Σ Note Σ Σ Σ Σ Σ Σ relationship Σ 1..1 Coding Patient relationship to subscriber Surface Codes ( Example ) Σ Σ originalRuleset Σ 0..1 Coding Original version Ruleset Codes ( Example )
Name Flags Card. Type Description & Constraints doco
. . ClaimResponse DomainResource Remittance resource
Elements defined in Ancestors: id , meta , implicitRules , language , text , contained , extension , modifierExtension
. . . identifier 0..* Identifier Response number
. . request . status Σ ?! 0..1 Reference ( Claim ) Id of resource triggering adjudication ruleset Σ 0..1 Coding code active | cancelled | draft | entered-in-error
Ruleset Financial Resource Status Codes ( Example Required )
. . originalRuleset . patient 0..1 Ruleset Codes Reference ( Example Patient ) The subject of the Products and Services
. . . created 0..1 dateTime Creation date
. . organization . insurer 0..1 Reference ( Organization ) Insurance issuing organization
. . . requestProvider 0..1 Reference ( Practitioner ) Responsible practitioner
. . . requestOrganization 0..1 Reference ( Organization ) Responsible organization
. . outcome . request Σ 0..1 Reference ( Claim ) Id of resource triggering adjudication
... outcome 0..1 code CodeableConcept complete | error | partial
RemittanceOutcome Claim Processing Codes ( Required Example )
. . . disposition 0..1 string Disposition Message
. . . payeeType 0..1 Coding CodeableConcept Party to be paid any benefits payable
Claim Payee Type Codes ( Example )
. . . item 0..* BackboneElement Line items
. . . . sequenceLinkId 1..1 positiveInt Service instance
. . . . noteNumber 0..* positiveInt List of note numbers which apply
. . . . adjudication 0..* BackboneElement Adjudication details
. . . . code . category 1..1 Coding CodeableConcept Adjudication category such as co-pay, eligible, benefit, etc.
Adjudication Value Codes ( Extensible Example )
. . . . amount . reason Σ 0..1 CodeableConcept Explanation of Adjudication outcome
Adjudication Reason Codes ( Example )
..... amount 0..1 Money Monetary amount
. . . . . value 0..1 decimal Non-monetary value
. . . . detail 0..* BackboneElement Detail line items
. . . . . sequenceLinkId 1..1 positiveInt Service instance
. . . . adjudication . noteNumber 0..* BackboneElement positiveInt List of note numbers which apply
. . . . code . adjudication 1..1 0..* see adjudication Detail level adjudication details
Adjudication Codes ( Extensible )
. . . . amount . subDetail 0..1 0..* Money BackboneElement Subdetail line items
. . . . . value . sequenceLinkId 0..1 1..1 decimal positiveInt Service instance
. . . . subDetail . . noteNumber 0..* BackboneElement positiveInt List of note numbers which apply
. . . . . sequenceLinkId . adjudication 1..1 0..* see adjudication Subdetail level adjudication details
. . adjudication . addItem 0..* BackboneElement Insurer added line items
. . . code . sequenceLinkId 1..1 0..* Coding positiveInt Service instances
Adjudication Codes ( Extensible )
. . . amount . revenue 0..1 Money CodeableConcept Revenue or cost center code
Example Revenue Center Codes ( Example )
. . . value . category 0..1 decimal CodeableConcept Type of service or product
Benefit SubCategory Codes Σ 0..* BackboneElement ( Example Insurer added line items )
. . . sequenceLinkId . service 0..* 0..1 positiveInt CodeableConcept Group, Service instances or Product
USCLS Codes ( Example )
. . . service . modifier 1..1 0..* Coding CodeableConcept Service/Product billing modifiers
USCLS Modifier type Codes ( Example )
. . . . fee 0..1 Money Professional fee or Product charge
. . . noteNumberLinkId . noteNumber 0..* positiveInt List of note numbers which apply
. . . . adjudication 0..* see adjudication Added items adjudication
. . . code . detail 1..1 0..* Coding BackboneElement Added items details
Adjudication Codes ( Extensible )
. . . . amount . revenue 0..1 Money CodeableConcept Revenue or cost center code
Example Revenue Center Codes ( Example )
. . . . value . category 0..1 decimal CodeableConcept Type of service or product
Benefit SubCategory Codes Σ 0..* BackboneElement ( Example Added items details )
. . . . . service 1..1 0..1 Coding CodeableConcept Service or Product
USCLS Codes ( Example )
. . . . fee . modifier 0..1 0..* Money CodeableConcept Service/Product billing modifiers
Modifier type Codes Σ 0..* BackboneElement ( Example )
. . . . code . fee 1..1 0..1 Coding Money Professional fee or Product charge
. . . . amount . noteNumber 0..1 0..* Money positiveInt List of note numbers which apply
. . . . value . adjudication 0..1 0..* see adjudication Added items detail adjudication
. . . error 0..* BackboneElement Processing errors
. . . . sequenceLinkId 0..1 positiveInt Item sequence number
. . . . detailSequenceLinkId 0..1 positiveInt Detail sequence number
. . . . subdetailSequenceLinkId 0..1 positiveInt Subdetail sequence number
. . . . code 1..1 Coding CodeableConcept Error code detailing processing issues
Adjudication Error Codes ( Required Example )
. . . totalCost 0..1 Money Total Cost of service from the Claim
. . . unallocDeductable 0..1 Money Unallocated deductible
. . . totalBenefit 0..1 Money Total benefit payable for the Claim
. . paymentAdjustment . payment Σ 0..1 BackboneElement Payment details, if paid
.... type 0..1 CodeableConcept Partial or Complete
Example Payment Type Codes ( Example )
.... adjustment 0..1 Money Payment adjustment for non-Claim issues
. . paymentAdjustmentReason . . adjustmentReason 0..1 Coding CodeableConcept Explanation for Payment the non-claim adjustment
Payment Adjustment Reason Codes ( Extensible Example )
. . paymentDate . . date 0..1 date Expected data of Payment
. . paymentAmount . . amount 0..1 Money Payable amount after adjustment
. . paymentRef . . identifier 0..1 Identifier Identifier of the payment instrument
. . . reserved 0..1 Coding Funds reserved status
Funds Reservation Codes ( Example )
. . . form 0..1 Coding CodeableConcept Printed Form Identifier
Form Codes ( Required Example )
. . note . processNote 0..* BackboneElement Processing notes
. . . . number 0..1 positiveInt Sequence Number for this note
. . . . type 0..1 Coding CodeableConcept display | print | printoper
NoteType ( Required )
. . . . text 0..1 string Note explanatory text
. . coverage . . language Σ 0..1 CodeableConcept Language if different from the resource
Common Languages ( Extensible but limited to All Languages )
... communicationRequest 0..* Reference ( CommunicationRequest ) Request for additional information
... insurance 0..* BackboneElement Insurance or medical plan
. . . . sequence 1..1 positiveInt Service instance identifier
. . . . focal 1..1 boolean Is the focal Coverage
. . . . coverage 1..1 Reference ( Coverage ) Insurance information
. . . . businessArrangement 0..1 string Business agreement
. . . . preAuthRef 0..* string Pre-Authorization/Determination Reference
. . . . claimResponse 0..1 Reference ( ClaimResponse ) Adjudication results

doco Documentation for this format

UML Diagram ( Legend )

ClaimResponse ( DomainResource ) The Response business identifier identifier : Identifier [0..*] Original request resource referrence request : Reference [0..1] « Claim » The version status of the style of resource contents. This should be mapped to instance (this element modifies the allowable profiles for this and supporting resources meaning of other elements) ruleset status : Coding code [0..1] « The static and dynamic model to which contents conform, which may be business version or standard/version. (Strength=Example) A code specifying the state of the resource instance. (Strength=Required) Ruleset ?? » Financial Resource Status ! The style (standard) and version of the original material which was converted into this resource Patient Resource originalRuleset patient : Coding Reference [0..1] « The static and dynamic model to which contents conform, which may be business version or standard/version. (Strength=Example) Ruleset Patient ?? » The date when the enclosed suite of services were performed or completed created : dateTime [0..1] The Insurer who produced this adjudicated response organization insurer : Reference [0..1] « Organization » The practitioner who is responsible for the services rendered to the patient requestProvider : Reference [0..1] « Practitioner » The organization which is responsible for the services rendered to the patient requestOrganization : Reference [0..1] « Organization » Original request resource referrence request : Reference [0..1] Claim Transaction status: error, Processing outcome errror, partial or complete processing outcome : code CodeableConcept [0..1] « The outcome result of the processing. (Strength=Required) claim processing (Strength=Example) RemittanceOutcome ! » Claim Processing ?? A description of the status of the adjudication disposition : string [0..1] Party to be reimbursed: Subscriber, provider, other payeeType : Coding CodeableConcept [0..1] « A code for the party to be reimbursed. (Strength=Example) Claim Payee Type ?? » The total cost of the services reported totalCost : Quantity ( Money ) [0..1] The amount of deductible applied which was not allocated to any particular service line unallocDeductable : Quantity ( Money ) [0..1] Total amount of benefit payable (Equal to sum of the Benefit amounts from all detail lines and additions less the Unallocated Deductible) totalBenefit : Quantity ( Money ) [0..1] Adjustment to the payment of this transaction which is not related to adjudication of this transaction paymentAdjustment : Quantity ( Money ) [0..1] Reason for the payment adjustment paymentAdjustmentReason : Coding [0..1] « Adjustment reason codes. (Strength=Extensible) Adjustment Reason + » Estimated payment data paymentDate : date [0..1] Payable less any payment adjustment paymentAmount : Quantity ( Money ) [0..1] Payment identifier paymentRef : Identifier [0..1] Status of funds reservation (For provider, for Patient, None) reserved : Coding [0..1] « For whom funds are to be reserved: (Patient, Provider, None). (Strength=Example) Funds Reservation ?? » The form to be used for printing the content form : Coding CodeableConcept [0..1] « The forms codes. (Strength=Required) (Strength=Example) Form ! » ?? Request for additional supporting or authorizing information, such as: documents, images or resources communicationRequest : Reference [0..*] CommunicationRequest Items Item A service line number sequenceLinkId : positiveInt [1..1] A list of note references to the notes provided below noteNumber : positiveInt [0..*] ItemAdjudication Adjudication Code indicating: Co-Pay, deductible, eligible, benefit, tax, etc code category : Coding CodeableConcept [1..1] « The adjudication codes. (Strength=Extensible) (Strength=Example) Adjudication Value + » ?? Adjudication reason such as limit reached reason : CodeableConcept [0..1] The adjudication reason codes. (Strength=Example) Adjudication Reason ?? Monetary amount associated with the code amount : Quantity ( Money ) [0..1] A non-monetary value for example a percentage. Mutually exclusive to the amount element above value : decimal [0..1] ItemDetail A service line number sequenceLinkId : positiveInt [1..1] DetailAdjudication Code indicating: Co-Pay, deductible, eligible, benefit, tax, etc code : Coding [1..1] « The adjudication codes. (Strength=Extensible) Adjudication + » Monetary amount associated with the code amount : Quantity ( Money ) [0..1] A non-monetary value for example a percentage. Mutually exclusive list of note references to the amount element above notes provided below value noteNumber : decimal positiveInt [0..1] [0..*] SubDetail A service line number sequenceLinkId : positiveInt [1..1] SubdetailAdjudication Code indicating: Co-Pay, deductible, eligible, benefit, tax, etc code : Coding [1..1] « The adjudication codes. (Strength=Extensible) Adjudication + » Monetary amount associated with the code amount : Quantity ( Money ) [0..1] A non-monetary value for example a percentage. Mutually exclusive list of note references to the amount element above notes provided below value noteNumber : decimal positiveInt [0..1] [0..*] AddedItem List of input service items which this service line is intended to replace sequenceLinkId : positiveInt [0..*] The type of reveneu or cost center providing the product and/or service revenue : CodeableConcept [0..1] Codes for the revenue or cost centers supplying the service and/or products. (Strength=Example) Example Revenue Center ?? Health Care Service Type Codes to identify the classification of service or benefits category : CodeableConcept [0..1] Benefit subcategories such as: oral-basic, major, glasses (Strength=Example) Benefit SubCategory ?? A code to indicate the Professional Service or Product supplied service : Coding CodeableConcept [1..1] « [0..1] Allowable service and product codes. (Strength=Example) USCLS ?? » Item typification or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or for medical whether the treatment was outside the clinic or out of office hours modifier : CodeableConcept [0..*] Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen. (Strength=Example) Modifier type ?? The fee charged for the professional service or product. fee : Quantity ( Money ) [0..1] A list of note references to the notes provided below noteNumberLinkId noteNumber : positiveInt [0..*] AddedItemAdjudication AddedItemsDetail Code indicating: Co-Pay, deductible, eligible, benefit, tax, etc The type of reveneu or cost center providing the product and/or service code revenue : Coding CodeableConcept [1..1] « [0..1] The adjudication codes. (Strength=Extensible) Codes for the revenue or cost centers supplying the service and/or products. (Strength=Example) Adjudication Example Revenue Center + » ?? Monetary amount associated with Health Care Service Type Codes to identify the code classification of service or benefits amount category : Quantity ( Money CodeableConcept ) [0..1] A non-monetary value for example a percentage. Mutually exclusive to the amount element above Benefit subcategories such as: oral-basic, major, glasses (Strength=Example) value : decimal Benefit SubCategory [0..1] AddedItemsDetail ?? A code to indicate the Professional Service or Product supplied service : Coding CodeableConcept [1..1] « [0..1] Allowable service and product codes. (Strength=Example) USCLS ?? » The fee charged Item typification or modifiers codes, eg for Oral whether the professional service treatment is cosmetic or product. fee : Quantity ( Money ) [0..1] AddedItemDetailAdjudication Code indicating: Co-Pay, deductible, eligible, benefit, tax, etc associated with TMJ, or for medical whether the treatment was outside the clinic or out of office hours code modifier : Coding CodeableConcept [1..1] « [0..*] The adjudication codes. (Strength=Extensible) Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen. (Strength=Example) Adjudication Modifier type + » ?? Monetary amount associated with The fee charged for the code professional service or product. amount fee : Quantity ( Money ) [0..1] A non-monetary value for example a percentage. Mutually exclusive list of note references to the amount element above notes provided below value noteNumber : decimal positiveInt [0..1] [0..*] Errors Error The sequence number of the line item submitted which contains the error. This value is omitted when the error is elsewhere sequenceLinkId : positiveInt [0..1] The sequence number of the addition within the line item submitted which contains the error. This value is omitted when the error is not related to an Addition detailSequenceLinkId : positiveInt [0..1] The sequence number of the addition within the line item submitted which contains the error. This value is omitted when the error is not related to an Addition subdetailSequenceLinkId : positiveInt [0..1] An error code,froma code,from a specified code system, which details why the claim could not be adjudicated code : Coding CodeableConcept [1..1] « The error codes for adjudication processing. (Strength=Required) error codes. (Strength=Example) Adjudication Error ! » ?? Notes Payment Whether this represents partial or complete payment of the claim type : CodeableConcept [0..1] The type (partial, complete) of the payment (Strength=Example) Example Payment Type ?? Adjustment to the payment of this transaction which is not related to adjudication of this transaction adjustment : Money [0..1] Reason for the payment adjustment adjustmentReason : CodeableConcept [0..1] Payment Adjustment reason codes. (Strength=Example) Payment Adjustment Reason ?? Estimated payment data date : date [0..1] Payable less any payment adjustment amount : Money [0..1] Payment identifier identifier : Identifier [0..1] Note An integer associated with each note which may be referred to from each service line item number : positiveInt [0..1] The note purpose: Print/Display type : Coding CodeableConcept [0..1] « The presentation types of notes. (Strength=Required) NoteType ! » The note text text : string [0..1] The ISO-639-1 alpha 2 code in lower case for the language, optionally followed by a hyphen and the ISO-3166-1 alpha 2 code for the region in upper case; e.g. "en" for English, or "en-US" for American English versus "en-EN" for England English language : CodeableConcept [0..1] A human language. (Strength=Extensible) Common Languages + Coverage Insurance A service line item sequence : positiveInt [1..1] The instance number of the Coverage which is the focus for adjudication. The Coverage against which the claim is to be adjudicated focal : boolean [1..1] Reference to the program or plan identification, underwriter or payor coverage : Reference [1..1] « Coverage » The contract number of a business agreement which describes the terms and conditions businessArrangement : string [0..1] The relationship of the patient to the subscriber relationship : Coding [1..1] « The code for the relationship of the patient to the subscriber. (Strength=Example) Surface ?? » A list of references from the Insurer to which these services pertain preAuthRef : string [0..*] The Coverages adjudication details claimResponse : Reference [0..1] « ClaimResponse » The style (standard) and version of the original material which was converted into this resource originalRuleset : Coding [0..1] « The static and dynamic model to which contents conform, which may be business version or standard/version. (Strength=Example) Ruleset ?? » The adjudications adjudication results adjudication [0..*] The adjudications results adjudication [0..*] The adjudications results adjudication [0..*] The third tier service adjudications for submitted services subDetail [0..*] The second tier service adjudications for submitted services detail [0..*] The first tier service adjudications for submitted services item [0..*] The adjudications results adjudication [0..*] The adjudications results adjudication [0..*] The second tier service adjudications for payor added services detail [0..*] The first tier service adjudications for payor added services addItem [0..*] Mutually exclusive with Services Provided (Item) error [0..*] Payment details for the claim if the claim has been paid payment [0..1] Note text note processNote [0..*] Financial instrument by which payment information for health care coverage insurance [0..*]

XML Template 

<

<ClaimResponse xmlns="http://hl7.org/fhir"> doco

 <!-- from Resource: id, meta, implicitRules, and language -->
 <!-- from DomainResource: text, contained, extension, and modifierExtension -->
 <</identifier>
 <</request>
 <</ruleset>
 <</originalRuleset>
 <
 <</organization>
 <</requestProvider>
 <</requestOrganization>
 <
 <
 <</payeeType>
 <
  <
  <
  <
   <</code>
   <</amount>
   <

 <identifier><!-- 0..* Identifier Response  number --></identifier>
 <status value="[code]"/><!-- 0..1 active | cancelled | draft | entered-in-error -->
 <patient><!-- 0..1 Reference(Patient) The subject of the Products and Services --></patient>
 <created value="[dateTime]"/><!-- 0..1 Creation date -->
 <insurer><!-- 0..1 Reference(Organization) Insurance issuing organization --></insurer>
 <requestProvider><!-- 0..1 Reference(Practitioner) Responsible practitioner --></requestProvider>
 <requestOrganization><!-- 0..1 Reference(Organization) Responsible organization --></requestOrganization>
 <request><!-- 0..1 Reference(Claim) Id of resource triggering adjudication --></request>
 <outcome><!-- 0..1 CodeableConcept complete | error | partial --></outcome>
 <disposition value="[string]"/><!-- 0..1 Disposition Message -->
 <payeeType><!-- 0..1 CodeableConcept Party to be paid any benefits payable --></payeeType>
 <item>  <!-- 0..* Line items -->
  <sequenceLinkId value="[positiveInt]"/><!-- 1..1 Service instance -->
  <noteNumber value="[positiveInt]"/><!-- 0..* List of note numbers which apply -->
  <adjudication>  <!-- 0..* Adjudication details -->
   <category><!-- 1..1 CodeableConcept Adjudication category such as co-pay, eligible, benefit, etc. --></category>
   <reason><!-- 0..1 CodeableConcept Explanation of Adjudication outcome --></reason>
   <amount><!-- 0..1 Money Monetary amount --></amount>
   <value value="[decimal]"/><!-- 0..1 Non-monetary value -->

  </adjudication>
  <
   <
   <
    <</code>
    <</amount>
    <
   </adjudication>
   <
    <
    <
     <</code>
     <</amount>
     <
    </adjudication>

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

   </subDetail>
  </detail>
 </item>
 <
  <
  <</service>
  <</fee>
  <
  <
   <</code>
   <</amount>
   <
  </adjudication>
  <
   <</service>
   <</fee>
   <
    <</code>
    <</amount>
    <
   </adjudication>

 <addItem>  <!-- 0..* Insurer added line items -->
  <sequenceLinkId value="[positiveInt]"/><!-- 0..* Service instances -->
  <revenue><!-- 0..1 CodeableConcept Revenue or cost center code --></revenue>
  <category><!-- 0..1 CodeableConcept Type of service or product --></category>
  <service><!-- 0..1 CodeableConcept Group, Service or Product --></service>
  <modifier><!-- 0..* CodeableConcept Service/Product billing modifiers --></modifier>
  <fee><!-- 0..1 Money Professional fee or Product charge --></fee>
  <noteNumber value="[positiveInt]"/><!-- 0..* List of note numbers which apply -->
  <adjudication><!-- 0..* Content as for ClaimResponse.item.adjudication Added items adjudication --></adjudication>
  <detail>  <!-- 0..* Added items details -->
   <revenue><!-- 0..1 CodeableConcept Revenue or cost center code --></revenue>
   <category><!-- 0..1 CodeableConcept Type of service or product --></category>
   <service><!-- 0..1 CodeableConcept Service or Product --></service>
   <modifier><!-- 0..* CodeableConcept Service/Product billing modifiers --></modifier>
   <fee><!-- 0..1 Money Professional fee or Product charge --></fee>
   <noteNumber value="[positiveInt]"/><!-- 0..* List of note numbers which apply -->
   <adjudication><!-- 0..* Content as for ClaimResponse.item.adjudication Added items detail adjudication --></adjudication>

  </detail>
 </addItem>
 <
  <
  <
  <
  <</code>

 <error>  <!-- 0..* Processing errors -->
  <sequenceLinkId value="[positiveInt]"/><!-- 0..1 Item sequence number -->
  <detailSequenceLinkId value="[positiveInt]"/><!-- 0..1 Detail sequence number -->
  <subdetailSequenceLinkId value="[positiveInt]"/><!-- 0..1 Subdetail sequence number -->
  <code><!-- 1..1 CodeableConcept Error code detailing processing issues --></code>

 </error>
 <</totalCost>
 <</unallocDeductable>
 <</totalBenefit>
 <</paymentAdjustment>
 <</paymentAdjustmentReason>
 <
 <</paymentAmount>
 <</paymentRef>
 <</reserved>
 <</form>
 <
  <
  <</type>
  <
 </note>
 <
  <
  <
  <</coverage>
  <
  <</relationship>
  <
  <</claimResponse>
  <</originalRuleset>
 </coverage>

 <totalCost><!-- 0..1 Money Total Cost of service from the Claim --></totalCost>
 <unallocDeductable><!-- 0..1 Money Unallocated deductible --></unallocDeductable>
 <totalBenefit><!-- 0..1 Money Total benefit payable for the Claim --></totalBenefit>
 <payment>  <!-- 0..1 Payment details, if paid -->
  <type><!-- 0..1 CodeableConcept Partial or Complete --></type>
  <adjustment><!-- 0..1 Money Payment adjustment for non-Claim issues --></adjustment>
  <adjustmentReason><!-- 0..1 CodeableConcept Explanation for the non-claim adjustment --></adjustmentReason>
  <date value="[date]"/><!-- 0..1 Expected data of Payment -->
  <amount><!-- 0..1 Money Payable amount after adjustment --></amount>
  <identifier><!-- 0..1 Identifier Identifier of the payment instrument --></identifier>
 </payment>
 <reserved><!-- 0..1 Coding Funds reserved status --></reserved>
 <form><!-- 0..1 CodeableConcept Printed Form Identifier --></form>
 <processNote>  <!-- 0..* Processing notes -->
  <number value="[positiveInt]"/><!-- 0..1 Sequence Number for this note -->
  <type><!-- 0..1 CodeableConcept display | print | printoper --></type>
  <text value="[string]"/><!-- 0..1 Note explanatory text -->
  <language><!-- 0..1 CodeableConcept Language if different from the resource --></language>
 </processNote>
 <communicationRequest><!-- 0..* Reference(CommunicationRequest) Request for additional information --></communicationRequest>
 <insurance>  <!-- 0..* Insurance or medical plan -->
  <sequence value="[positiveInt]"/><!-- 1..1 Service instance identifier -->
  <focal value="[boolean]"/><!-- 1..1 Is the focal Coverage -->
  <coverage><!-- 1..1 Reference(Coverage) Insurance information --></coverage>
  <businessArrangement value="[string]"/><!-- 0..1 Business agreement -->
  <preAuthRef value="[string]"/><!-- 0..* Pre-Authorization/Determination Reference -->
  <claimResponse><!-- 0..1 Reference(ClaimResponse) Adjudication results --></claimResponse>
 </insurance>

</ClaimResponse>

JSON Template 

{
  "resourceType" : "",

{doco
  "resourceType" : "ClaimResponse",

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

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

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

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

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

  "addItem" : [{ // Insurer added line items
    "sequenceLinkId" : ["<positiveInt>"], // Service instances
    "revenue" : { CodeableConcept }, // Revenue or cost center code
    "category" : { CodeableConcept }, // Type of service or product
    "service" : { CodeableConcept }, // Group, Service or Product
    "modifier" : [{ CodeableConcept }], // Service/Product billing modifiers
    "fee" : { Money }, // Professional fee or Product charge
    "noteNumber" : ["<positiveInt>"], // List of note numbers which apply
    "adjudication" : [{ Content as for ClaimResponse.item.adjudication }], // Added items adjudication
    "detail" : [{ // Added items details
      "revenue" : { CodeableConcept }, // Revenue or cost center code
      "category" : { CodeableConcept }, // Type of service or product
      "service" : { CodeableConcept }, // Service or Product
      "modifier" : [{ CodeableConcept }], // Service/Product billing modifiers
      "fee" : { Money }, // Professional fee or Product charge
      "noteNumber" : ["<positiveInt>"], // List of note numbers which apply
      "adjudication" : [{ Content as for ClaimResponse.item.adjudication }] // Added items detail adjudication

    }]
  }],
  "
    "
    "
    "
    "

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

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

  "totalCost" : { Money }, // Total Cost of service from the Claim
  "unallocDeductable" : { Money }, // Unallocated deductible
  "totalBenefit" : { Money }, // Total benefit payable for the Claim
  "payment" : { // Payment details, if paid
    "type" : { CodeableConcept }, // Partial or Complete
    "adjustment" : { Money }, // Payment adjustment for non-Claim issues
    "adjustmentReason" : { CodeableConcept }, // Explanation for the non-claim adjustment
    "date" : "<date>", // Expected data of Payment
    "amount" : { Money }, // Payable amount after adjustment
    "identifier" : { Identifier } // Identifier of the payment instrument
  },
  "reserved" : { Coding }, // Funds reserved status
  "form" : { CodeableConcept }, // Printed Form Identifier
  "processNote" : [{ // Processing notes
    "number" : "<positiveInt>", // Sequence Number for this note
    "type" : { CodeableConcept }, // display | print | printoper
    "text" : "<string>", // Note explanatory text
    "language" : { CodeableConcept } // Language if different from the resource

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

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

  }]
}

Turtle Template 


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


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

  # from Resource: .id, .meta, .implicitRules, and .language
  # from DomainResource: .text, .contained, .extension, and .modifierExtension
  fhir:ClaimResponse.identifier [ Identifier ], ... ; # 0..* Response  number
  fhir:ClaimResponse.status [ code ]; # 0..1 active | cancelled | draft | entered-in-error
  fhir:ClaimResponse.patient [ Reference(Patient) ]; # 0..1 The subject of the Products and Services
  fhir:ClaimResponse.created [ dateTime ]; # 0..1 Creation date
  fhir:ClaimResponse.insurer [ Reference(Organization) ]; # 0..1 Insurance issuing organization
  fhir:ClaimResponse.requestProvider [ Reference(Practitioner) ]; # 0..1 Responsible practitioner
  fhir:ClaimResponse.requestOrganization [ Reference(Organization) ]; # 0..1 Responsible organization
  fhir:ClaimResponse.request [ Reference(Claim) ]; # 0..1 Id of resource triggering adjudication
  fhir:ClaimResponse.outcome [ CodeableConcept ]; # 0..1 complete | error | partial
  fhir:ClaimResponse.disposition [ string ]; # 0..1 Disposition Message
  fhir:ClaimResponse.payeeType [ CodeableConcept ]; # 0..1 Party to be paid any benefits payable
  fhir:ClaimResponse.item [ # 0..* Line items
    fhir:ClaimResponse.item.sequenceLinkId [ positiveInt ]; # 1..1 Service instance
    fhir:ClaimResponse.item.noteNumber [ positiveInt ], ... ; # 0..* List of note numbers which apply
    fhir:ClaimResponse.item.adjudication [ # 0..* Adjudication details
      fhir:ClaimResponse.item.adjudication.category [ CodeableConcept ]; # 1..1 Adjudication category such as co-pay, eligible, benefit, etc.
      fhir:ClaimResponse.item.adjudication.reason [ CodeableConcept ]; # 0..1 Explanation of Adjudication outcome
      fhir:ClaimResponse.item.adjudication.amount [ Money ]; # 0..1 Monetary amount
      fhir:ClaimResponse.item.adjudication.value [ decimal ]; # 0..1 Non-monetary value
    ], ...;
    fhir:ClaimResponse.item.detail [ # 0..* Detail line items
      fhir:ClaimResponse.item.detail.sequenceLinkId [ positiveInt ]; # 1..1 Service instance
      fhir:ClaimResponse.item.detail.noteNumber [ positiveInt ], ... ; # 0..* List of note numbers which apply
      fhir:ClaimResponse.item.detail.adjudication [ See ClaimResponse.item.adjudication ], ... ; # 0..* Detail level adjudication details
      fhir:ClaimResponse.item.detail.subDetail [ # 0..* Subdetail line items
        fhir:ClaimResponse.item.detail.subDetail.sequenceLinkId [ positiveInt ]; # 1..1 Service instance
        fhir:ClaimResponse.item.detail.subDetail.noteNumber [ positiveInt ], ... ; # 0..* List of note numbers which apply
        fhir:ClaimResponse.item.detail.subDetail.adjudication [ See ClaimResponse.item.adjudication ], ... ; # 0..* Subdetail level adjudication details
      ], ...;
    ], ...;
  ], ...;
  fhir:ClaimResponse.addItem [ # 0..* Insurer added line items
    fhir:ClaimResponse.addItem.sequenceLinkId [ positiveInt ], ... ; # 0..* Service instances
    fhir:ClaimResponse.addItem.revenue [ CodeableConcept ]; # 0..1 Revenue or cost center code
    fhir:ClaimResponse.addItem.category [ CodeableConcept ]; # 0..1 Type of service or product
    fhir:ClaimResponse.addItem.service [ CodeableConcept ]; # 0..1 Group, Service or Product
    fhir:ClaimResponse.addItem.modifier [ CodeableConcept ], ... ; # 0..* Service/Product billing modifiers
    fhir:ClaimResponse.addItem.fee [ Money ]; # 0..1 Professional fee or Product charge
    fhir:ClaimResponse.addItem.noteNumber [ positiveInt ], ... ; # 0..* List of note numbers which apply
    fhir:ClaimResponse.addItem.adjudication [ See ClaimResponse.item.adjudication ], ... ; # 0..* Added items adjudication
    fhir:ClaimResponse.addItem.detail [ # 0..* Added items details
      fhir:ClaimResponse.addItem.detail.revenue [ CodeableConcept ]; # 0..1 Revenue or cost center code
      fhir:ClaimResponse.addItem.detail.category [ CodeableConcept ]; # 0..1 Type of service or product
      fhir:ClaimResponse.addItem.detail.service [ CodeableConcept ]; # 0..1 Service or Product
      fhir:ClaimResponse.addItem.detail.modifier [ CodeableConcept ], ... ; # 0..* Service/Product billing modifiers
      fhir:ClaimResponse.addItem.detail.fee [ Money ]; # 0..1 Professional fee or Product charge
      fhir:ClaimResponse.addItem.detail.noteNumber [ positiveInt ], ... ; # 0..* List of note numbers which apply
      fhir:ClaimResponse.addItem.detail.adjudication [ See ClaimResponse.item.adjudication ], ... ; # 0..* Added items detail adjudication
    ], ...;
  ], ...;
  fhir:ClaimResponse.error [ # 0..* Processing errors
    fhir:ClaimResponse.error.sequenceLinkId [ positiveInt ]; # 0..1 Item sequence number
    fhir:ClaimResponse.error.detailSequenceLinkId [ positiveInt ]; # 0..1 Detail sequence number
    fhir:ClaimResponse.error.subdetailSequenceLinkId [ positiveInt ]; # 0..1 Subdetail sequence number
    fhir:ClaimResponse.error.code [ CodeableConcept ]; # 1..1 Error code detailing processing issues
  ], ...;
  fhir:ClaimResponse.totalCost [ Money ]; # 0..1 Total Cost of service from the Claim
  fhir:ClaimResponse.unallocDeductable [ Money ]; # 0..1 Unallocated deductible
  fhir:ClaimResponse.totalBenefit [ Money ]; # 0..1 Total benefit payable for the Claim
  fhir:ClaimResponse.payment [ # 0..1 Payment details, if paid
    fhir:ClaimResponse.payment.type [ CodeableConcept ]; # 0..1 Partial or Complete
    fhir:ClaimResponse.payment.adjustment [ Money ]; # 0..1 Payment adjustment for non-Claim issues
    fhir:ClaimResponse.payment.adjustmentReason [ CodeableConcept ]; # 0..1 Explanation for the non-claim adjustment
    fhir:ClaimResponse.payment.date [ date ]; # 0..1 Expected data of Payment
    fhir:ClaimResponse.payment.amount [ Money ]; # 0..1 Payable amount after adjustment
    fhir:ClaimResponse.payment.identifier [ Identifier ]; # 0..1 Identifier of the payment instrument
  ];
  fhir:ClaimResponse.reserved [ Coding ]; # 0..1 Funds reserved status
  fhir:ClaimResponse.form [ CodeableConcept ]; # 0..1 Printed Form Identifier
  fhir:ClaimResponse.processNote [ # 0..* Processing notes
    fhir:ClaimResponse.processNote.number [ positiveInt ]; # 0..1 Sequence Number for this note
    fhir:ClaimResponse.processNote.type [ CodeableConcept ]; # 0..1 display | print | printoper
    fhir:ClaimResponse.processNote.text [ string ]; # 0..1 Note explanatory text
    fhir:ClaimResponse.processNote.language [ CodeableConcept ]; # 0..1 Language if different from the resource
  ], ...;
  fhir:ClaimResponse.communicationRequest [ Reference(CommunicationRequest) ], ... ; # 0..* Request for additional information
  fhir:ClaimResponse.insurance [ # 0..* Insurance or medical plan
    fhir:ClaimResponse.insurance.sequence [ positiveInt ]; # 1..1 Service instance identifier
    fhir:ClaimResponse.insurance.focal [ boolean ]; # 1..1 Is the focal Coverage
    fhir:ClaimResponse.insurance.coverage [ Reference(Coverage) ]; # 1..1 Insurance information
    fhir:ClaimResponse.insurance.businessArrangement [ string ]; # 0..1 Business agreement
    fhir:ClaimResponse.insurance.preAuthRef [ string ], ... ; # 0..* Pre-Authorization/Determination Reference
    fhir:ClaimResponse.insurance.claimResponse [ Reference(ClaimResponse) ]; # 0..1 Adjudication results
  ], ...;
]

Changes since DSTU2

ClaimResponse
ClaimResponse.status
  • Added Element
ClaimResponse.patient
  • Added Element
ClaimResponse.insurer
  • Added Element
ClaimResponse.outcome
  • Type changed from code to CodeableConcept
  • Remove Binding http://hl7.org/fhir/ValueSet/remittance-outcome (required)
ClaimResponse.payeeType
  • Type changed from Coding to CodeableConcept
ClaimResponse.item.adjudication.category
  • Added Element
ClaimResponse.item.adjudication.reason
  • Added Element
ClaimResponse.item.adjudication.amount
  • Type changed from Quantity{http://hl7.org/fhir/StructureDefinition/Money} to Money
ClaimResponse.item.detail.noteNumber
  • Added Element
ClaimResponse.item.detail.adjudication
  • Remove BackboneElement
ClaimResponse.item.detail.subDetail.noteNumber
  • Added Element
ClaimResponse.item.detail.subDetail.adjudication
  • Remove BackboneElement
ClaimResponse.addItem.revenue
  • Added Element
ClaimResponse.addItem.category
  • Added Element
ClaimResponse.addItem.service
  • Min Cardinality changed from 1 to 0
  • Type changed from Coding to CodeableConcept
ClaimResponse.addItem.modifier
  • Added Element
ClaimResponse.addItem.fee
  • Type changed from Quantity{http://hl7.org/fhir/StructureDefinition/Money} to Money
ClaimResponse.addItem.noteNumber
  • Added Element
ClaimResponse.addItem.adjudication
  • Remove BackboneElement
ClaimResponse.addItem.detail.revenue
  • Added Element
ClaimResponse.addItem.detail.category
  • Added Element
ClaimResponse.addItem.detail.service
  • Min Cardinality changed from 1 to 0
  • Type changed from Coding to CodeableConcept
ClaimResponse.addItem.detail.modifier
  • Added Element
ClaimResponse.addItem.detail.fee
  • Type changed from Quantity{http://hl7.org/fhir/StructureDefinition/Money} to Money
ClaimResponse.addItem.detail.noteNumber
  • Added Element
ClaimResponse.addItem.detail.adjudication
  • Remove BackboneElement
ClaimResponse.error.code
  • Type changed from Coding to CodeableConcept
  • Remove Binding http://hl7.org/fhir/ValueSet/adjudication-error (required)
ClaimResponse.totalCost
  • Type changed from Quantity{http://hl7.org/fhir/StructureDefinition/Money} to Money
ClaimResponse.unallocDeductable
  • Type changed from Quantity{http://hl7.org/fhir/StructureDefinition/Money} to Money
ClaimResponse.totalBenefit
  • Type changed from Quantity{http://hl7.org/fhir/StructureDefinition/Money} to Money
ClaimResponse.payment
  • Added Element
ClaimResponse.payment.type
  • Added Element
ClaimResponse.payment.adjustment
  • Added Element
ClaimResponse.payment.adjustmentReason
  • Added Element
ClaimResponse.payment.date
  • Added Element
ClaimResponse.payment.amount
  • Added Element
ClaimResponse.payment.identifier
  • Added Element
ClaimResponse.form
  • Type changed from Coding to CodeableConcept
  • Remove Binding http://hl7.org/fhir/ValueSet/forms (required)
ClaimResponse.processNote
  • Added Element
ClaimResponse.processNote.number
  • Added Element
ClaimResponse.processNote.type
  • Added Element
ClaimResponse.processNote.text
  • Added Element
ClaimResponse.processNote.language
  • Added Element
ClaimResponse.communicationRequest
  • Added Element
ClaimResponse.insurance
  • Added Element
ClaimResponse.insurance.sequence
  • Added Element
ClaimResponse.insurance.focal
  • Added Element
ClaimResponse.insurance.coverage
  • Added Element
ClaimResponse.insurance.businessArrangement
  • Added Element
ClaimResponse.insurance.preAuthRef
  • Added Element
ClaimResponse.insurance.claimResponse
  • Added Element
ClaimResponse.ruleset
  • deleted
ClaimResponse.originalRuleset
  • deleted
ClaimResponse.organization
  • deleted
ClaimResponse.item.adjudication.code
  • deleted
ClaimResponse.item.detail.adjudication.code
  • deleted
ClaimResponse.item.detail.adjudication.amount
  • deleted
ClaimResponse.item.detail.adjudication.value
  • deleted
ClaimResponse.item.detail.subDetail.adjudication.code
  • deleted
ClaimResponse.item.detail.subDetail.adjudication.amount
  • deleted
ClaimResponse.item.detail.subDetail.adjudication.value
  • deleted
ClaimResponse.addItem.noteNumberLinkId
  • deleted
ClaimResponse.addItem.adjudication.code
  • deleted
ClaimResponse.addItem.adjudication.amount
  • deleted
ClaimResponse.addItem.adjudication.value
  • deleted
ClaimResponse.addItem.detail.adjudication.code
  • deleted
ClaimResponse.addItem.detail.adjudication.amount
  • deleted
ClaimResponse.addItem.detail.adjudication.value
  • deleted
ClaimResponse.paymentAdjustment
  • deleted
ClaimResponse.paymentAdjustmentReason
  • deleted
ClaimResponse.paymentDate
  • deleted
ClaimResponse.paymentAmount
  • deleted
ClaimResponse.paymentRef
  • deleted
ClaimResponse.note
  • deleted
ClaimResponse.coverage
  • deleted

See the Full Difference for further information

This analysis is available as XML or JSON .

Structure

Σ Σ Resource version Σ Coding Original version Σ Σ Insurer Σ Σ Σ Σ Σ Σ Σ Σ Σ Σ Σ Σ Σ Detail adjudication Σ Coding Adjudication category such as co-pay, eligible, benefit, etc. Σ Monetary amount Σ Non-monetary value Σ Subdetail line items Σ positiveInt Service instance Σ Subdetail adjudication Σ Adjudication category such as co-pay, eligible, benefit, etc. Σ Monetary amount Σ Non-monetary value addItem Σ Σ Group, Service or Product Σ Σ Σ BackboneElement Σ Adjudication category such as co-pay, eligible, benefit, etc. Σ Monetary amount Σ Non-monetary value detail Σ Σ Professional fee or Product charge adjudication Added items detail adjudication Σ Adjudication category such as co-pay, eligible, benefit, etc. Adjudication Codes ( Extensible ) Σ Monetary amount Σ decimal Non-monetary value Σ Σ Σ Σ Σ Σ Σ Σ Σ Reason Σ Σ Payment Σ Payment identifier Σ Σ Σ Σ Note Σ Σ Σ Σ Σ Σ relationship Σ 1..1 Coding Patient relationship to subscriber Surface Codes ( Example ) Σ Σ originalRuleset Σ 0..1 Coding Original version Ruleset Codes ( Example )
Name Flags Card. Type Description & Constraints doco
. . ClaimResponse DomainResource Remittance resource
Elements defined in Ancestors: id , meta , implicitRules , language , text , contained , extension , modifierExtension
. . . identifier 0..* Identifier Response number
. . request . status Σ ?! 0..1 Reference ( Claim ) Id of resource triggering adjudication ruleset Σ 0..1 Coding code active | cancelled | draft | entered-in-error
Ruleset Financial Resource Status Codes ( Example Required )
. . originalRuleset . patient 0..1 Ruleset Codes Reference ( Example Patient ) The subject of the Products and Services
. . . created 0..1 dateTime Creation date
. . organization . insurer 0..1 Reference ( Organization ) Insurance issuing organization
. . . requestProvider 0..1 Reference ( Practitioner ) Responsible practitioner
. . . requestOrganization 0..1 Reference ( Organization ) Responsible organization
. . outcome . request Σ 0..1 Reference ( Claim ) Id of resource triggering adjudication
... outcome 0..1 code CodeableConcept complete | error | partial
RemittanceOutcome Claim Processing Codes ( Required Example )
. . . disposition 0..1 string Disposition Message
. . . payeeType 0..1 Coding CodeableConcept Party to be paid any benefits payable
Claim Payee Type Codes ( Example )
. . . item 0..* BackboneElement Line items
. . . . sequenceLinkId 1..1 positiveInt Service instance
. . . . noteNumber 0..* positiveInt List of note numbers which apply
. . . . adjudication 0..* BackboneElement Adjudication details
. . . . code . category 1..1 Coding CodeableConcept Adjudication category such as co-pay, eligible, benefit, etc.
Adjudication Value Codes ( Extensible Example )
. . . . amount . reason Σ 0..1 CodeableConcept Explanation of Adjudication outcome
Adjudication Reason Codes ( Example )
..... amount 0..1 Money Monetary amount
. . . . . value 0..1 decimal Non-monetary value
. . . . detail 0..* BackboneElement Detail line items
. . . . . sequenceLinkId 1..1 positiveInt Service instance
. . . . adjudication . noteNumber 0..* BackboneElement positiveInt List of note numbers which apply
. . . . code . adjudication 1..1 0..* see adjudication Detail level adjudication details
Adjudication Codes ( Extensible )
. . . . amount . subDetail 0..1 0..* Money BackboneElement Subdetail line items
. . . . . value . sequenceLinkId 0..1 1..1 decimal positiveInt Service instance
. . . . subDetail . . noteNumber 0..* BackboneElement positiveInt List of note numbers which apply
. . . . . sequenceLinkId . adjudication 1..1 0..* see adjudication Subdetail level adjudication details
. . adjudication . addItem 0..* BackboneElement Insurer added line items
. . . code . sequenceLinkId 1..1 0..* Coding positiveInt Service instances
Adjudication Codes ( Extensible )
. . . amount . revenue 0..1 Money CodeableConcept Revenue or cost center code
Example Revenue Center Codes ( Example )
. . . value . category 0..1 decimal CodeableConcept Type of service or product
Benefit SubCategory Codes Σ 0..* BackboneElement ( Example Insurer added line items )
. . . sequenceLinkId . service 0..* 0..1 positiveInt CodeableConcept Group, Service instances or Product
USCLS Codes ( Example )
. . . service . modifier 1..1 0..* Coding CodeableConcept Service/Product billing modifiers
USCLS Modifier type Codes ( Example )
. . . . fee 0..1 Money Professional fee or Product charge
. . . noteNumberLinkId . noteNumber 0..* positiveInt List of note numbers which apply
. . . . adjudication 0..* see adjudication Added items adjudication
. . . code . detail 1..1 0..* Coding BackboneElement Added items details
Adjudication Codes ( Extensible )
. . . . amount . revenue 0..1 Money CodeableConcept Revenue or cost center code
Example Revenue Center Codes ( Example )
. . . . value . category 0..1 decimal CodeableConcept Type of service or product
Benefit SubCategory Codes Σ 0..* BackboneElement ( Example Added items details )
. . . . . service 1..1 0..1 Coding CodeableConcept Service or Product
USCLS Codes ( Example )
. . . . fee . modifier 0..1 0..* Money CodeableConcept Service/Product billing modifiers
Modifier type Codes Σ 0..* BackboneElement ( Example )
. . . . code . fee 1..1 0..1 Coding Money Professional fee or Product charge
. . . . amount . noteNumber 0..1 0..* Money positiveInt List of note numbers which apply
. . . . value . adjudication 0..1 0..* see adjudication Added items detail adjudication
. . . error 0..* BackboneElement Processing errors
. . . . sequenceLinkId 0..1 positiveInt Item sequence number
. . . . detailSequenceLinkId 0..1 positiveInt Detail sequence number
. . . . subdetailSequenceLinkId 0..1 positiveInt Subdetail sequence number
. . . . code 1..1 Coding CodeableConcept Error code detailing processing issues
Adjudication Error Codes ( Required Example )
. . . totalCost 0..1 Money Total Cost of service from the Claim
. . . unallocDeductable 0..1 Money Unallocated deductible
. . . totalBenefit 0..1 Money Total benefit payable for the Claim
. . paymentAdjustment . payment Σ 0..1 BackboneElement Payment details, if paid
.... type 0..1 CodeableConcept Partial or Complete
Example Payment Type Codes ( Example )
.... adjustment 0..1 Money Payment adjustment for non-Claim issues
. . paymentAdjustmentReason . . adjustmentReason 0..1 Coding CodeableConcept Explanation for Payment the non-claim adjustment
Payment Adjustment Reason Codes ( Extensible Example )
. . paymentDate . . date 0..1 date Expected data of Payment
. . paymentAmount . . amount 0..1 Money Payable amount after adjustment
. . paymentRef . . identifier 0..1 Identifier Identifier of the payment instrument
. . . reserved 0..1 Coding Funds reserved status
Funds Reservation Codes ( Example )
. . . form 0..1 Coding CodeableConcept Printed Form Identifier
Form Codes ( Required Example )
. . note . processNote 0..* BackboneElement Processing notes
. . . . number 0..1 positiveInt Sequence Number for this note
. . . . type 0..1 Coding CodeableConcept display | print | printoper
NoteType ( Required )
. . . . text 0..1 string Note explanatory text
. . coverage . . language Σ 0..1 CodeableConcept Language if different from the resource
Common Languages ( Extensible but limited to All Languages )
... communicationRequest 0..* Reference ( CommunicationRequest ) Request for additional information
... insurance 0..* BackboneElement Insurance or medical plan
. . . . sequence 1..1 positiveInt Service instance identifier
. . . . focal 1..1 boolean Is the focal Coverage
. . . . coverage 1..1 Reference ( Coverage ) Insurance information
. . . . businessArrangement 0..1 string Business agreement
. . . . preAuthRef 0..* string Pre-Authorization/Determination Reference
. . . . claimResponse 0..1 Reference ( ClaimResponse ) Adjudication results

doco Documentation for this format

UML Diagram ( Legend )

ClaimResponse ( DomainResource ) The Response business identifier identifier : Identifier [0..*] Original request resource referrence request : Reference [0..1] « Claim » The version status of the style of resource contents. This should be mapped to instance (this element modifies the allowable profiles for this and supporting resources meaning of other elements) ruleset status : Coding code [0..1] « The static and dynamic model to which contents conform, which may be business version or standard/version. (Strength=Example) A code specifying the state of the resource instance. (Strength=Required) Ruleset ?? » Financial Resource Status ! The style (standard) and version of the original material which was converted into this resource Patient Resource originalRuleset patient : Coding Reference [0..1] « The static and dynamic model to which contents conform, which may be business version or standard/version. (Strength=Example) Ruleset Patient ?? » The date when the enclosed suite of services were performed or completed created : dateTime [0..1] The Insurer who produced this adjudicated response organization insurer : Reference [0..1] « Organization » The practitioner who is responsible for the services rendered to the patient requestProvider : Reference [0..1] « Practitioner » The organization which is responsible for the services rendered to the patient requestOrganization : Reference [0..1] « Organization » Original request resource referrence request : Reference [0..1] Claim Transaction status: error, Processing outcome errror, partial or complete processing outcome : code CodeableConcept [0..1] « The outcome result of the processing. (Strength=Required) claim processing (Strength=Example) RemittanceOutcome ! » Claim Processing ?? A description of the status of the adjudication disposition : string [0..1] Party to be reimbursed: Subscriber, provider, other payeeType : Coding CodeableConcept [0..1] « A code for the party to be reimbursed. (Strength=Example) Claim Payee Type ?? » The total cost of the services reported totalCost : Quantity ( Money ) [0..1] The amount of deductible applied which was not allocated to any particular service line unallocDeductable : Quantity ( Money ) [0..1] Total amount of benefit payable (Equal to sum of the Benefit amounts from all detail lines and additions less the Unallocated Deductible) totalBenefit : Quantity ( Money ) [0..1] Adjustment to the payment of this transaction which is not related to adjudication of this transaction paymentAdjustment : Quantity ( Money ) [0..1] Reason for the payment adjustment paymentAdjustmentReason : Coding [0..1] « Adjustment reason codes. (Strength=Extensible) Adjustment Reason + » Estimated payment data paymentDate : date [0..1] Payable less any payment adjustment paymentAmount : Quantity ( Money ) [0..1] Payment identifier paymentRef : Identifier [0..1] Status of funds reservation (For provider, for Patient, None) reserved : Coding [0..1] « For whom funds are to be reserved: (Patient, Provider, None). (Strength=Example) Funds Reservation ?? » The form to be used for printing the content form : Coding CodeableConcept [0..1] « The forms codes. (Strength=Required) (Strength=Example) Form ! » ?? Request for additional supporting or authorizing information, such as: documents, images or resources communicationRequest : Reference [0..*] CommunicationRequest Items Item A service line number sequenceLinkId : positiveInt [1..1] A list of note references to the notes provided below noteNumber : positiveInt [0..*] ItemAdjudication Adjudication Code indicating: Co-Pay, deductible, eligible, benefit, tax, etc code category : Coding CodeableConcept [1..1] « The adjudication codes. (Strength=Extensible) (Strength=Example) Adjudication Value + » ?? Adjudication reason such as limit reached reason : CodeableConcept [0..1] The adjudication reason codes. (Strength=Example) Adjudication Reason ?? Monetary amount associated with the code amount : Quantity ( Money ) [0..1] A non-monetary value for example a percentage. Mutually exclusive to the amount element above value : decimal [0..1] ItemDetail A service line number sequenceLinkId : positiveInt [1..1] DetailAdjudication Code indicating: Co-Pay, deductible, eligible, benefit, tax, etc code : Coding [1..1] « The adjudication codes. (Strength=Extensible) Adjudication + » Monetary amount associated with the code amount : Quantity ( Money ) [0..1] A non-monetary value for example a percentage. Mutually exclusive list of note references to the amount element above notes provided below value noteNumber : decimal positiveInt [0..1] [0..*] SubDetail A service line number sequenceLinkId : positiveInt [1..1] SubdetailAdjudication Code indicating: Co-Pay, deductible, eligible, benefit, tax, etc code : Coding [1..1] « The adjudication codes. (Strength=Extensible) Adjudication + » Monetary amount associated with the code amount : Quantity ( Money ) [0..1] A non-monetary value for example a percentage. Mutually exclusive list of note references to the amount element above notes provided below value noteNumber : decimal positiveInt [0..1] [0..*] AddedItem List of input service items which this service line is intended to replace sequenceLinkId : positiveInt [0..*] The type of reveneu or cost center providing the product and/or service revenue : CodeableConcept [0..1] Codes for the revenue or cost centers supplying the service and/or products. (Strength=Example) Example Revenue Center ?? Health Care Service Type Codes to identify the classification of service or benefits category : CodeableConcept [0..1] Benefit subcategories such as: oral-basic, major, glasses (Strength=Example) Benefit SubCategory ?? A code to indicate the Professional Service or Product supplied service : Coding CodeableConcept [1..1] « [0..1] Allowable service and product codes. (Strength=Example) USCLS ?? » Item typification or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or for medical whether the treatment was outside the clinic or out of office hours modifier : CodeableConcept [0..*] Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen. (Strength=Example) Modifier type ?? The fee charged for the professional service or product. fee : Quantity ( Money ) [0..1] A list of note references to the notes provided below noteNumberLinkId noteNumber : positiveInt [0..*] AddedItemAdjudication AddedItemsDetail Code indicating: Co-Pay, deductible, eligible, benefit, tax, etc The type of reveneu or cost center providing the product and/or service code revenue : Coding CodeableConcept [1..1] « [0..1] The adjudication codes. (Strength=Extensible) Codes for the revenue or cost centers supplying the service and/or products. (Strength=Example) Adjudication Example Revenue Center + » ?? Monetary amount associated with Health Care Service Type Codes to identify the code classification of service or benefits amount category : Quantity ( Money CodeableConcept ) [0..1] A non-monetary value for example a percentage. Mutually exclusive to the amount element above Benefit subcategories such as: oral-basic, major, glasses (Strength=Example) value : decimal Benefit SubCategory [0..1] AddedItemsDetail ?? A code to indicate the Professional Service or Product supplied service : Coding CodeableConcept [1..1] « [0..1] Allowable service and product codes. (Strength=Example) USCLS ?? » The fee charged Item typification or modifiers codes, eg for Oral whether the professional service treatment is cosmetic or product. fee : Quantity ( Money ) [0..1] AddedItemDetailAdjudication Code indicating: Co-Pay, deductible, eligible, benefit, tax, etc associated with TMJ, or for medical whether the treatment was outside the clinic or out of office hours code modifier : Coding CodeableConcept [1..1] « [0..*] The adjudication codes. (Strength=Extensible) Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen. (Strength=Example) Adjudication Modifier type + » ?? Monetary amount associated with The fee charged for the code professional service or product. amount fee : Quantity ( Money ) [0..1] A non-monetary value for example a percentage. Mutually exclusive list of note references to the amount element above notes provided below value noteNumber : decimal positiveInt [0..1] [0..*] Errors Error The sequence number of the line item submitted which contains the error. This value is omitted when the error is elsewhere sequenceLinkId : positiveInt [0..1] The sequence number of the addition within the line item submitted which contains the error. This value is omitted when the error is not related to an Addition detailSequenceLinkId : positiveInt [0..1] The sequence number of the addition within the line item submitted which contains the error. This value is omitted when the error is not related to an Addition subdetailSequenceLinkId : positiveInt [0..1] An error code,froma code,from a specified code system, which details why the claim could not be adjudicated code : Coding CodeableConcept [1..1] « The error codes for adjudication processing. (Strength=Required) error codes. (Strength=Example) Adjudication Error ! » ?? Notes Payment Whether this represents partial or complete payment of the claim type : CodeableConcept [0..1] The type (partial, complete) of the payment (Strength=Example) Example Payment Type ?? Adjustment to the payment of this transaction which is not related to adjudication of this transaction adjustment : Money [0..1] Reason for the payment adjustment adjustmentReason : CodeableConcept [0..1] Payment Adjustment reason codes. (Strength=Example) Payment Adjustment Reason ?? Estimated payment data date : date [0..1] Payable less any payment adjustment amount : Money [0..1] Payment identifier identifier : Identifier [0..1] Note An integer associated with each note which may be referred to from each service line item number : positiveInt [0..1] The note purpose: Print/Display type : Coding CodeableConcept [0..1] « The presentation types of notes. (Strength=Required) NoteType ! » The note text text : string [0..1] The ISO-639-1 alpha 2 code in lower case for the language, optionally followed by a hyphen and the ISO-3166-1 alpha 2 code for the region in upper case; e.g. "en" for English, or "en-US" for American English versus "en-EN" for England English language : CodeableConcept [0..1] A human language. (Strength=Extensible) Common Languages + Coverage Insurance A service line item sequence : positiveInt [1..1] The instance number of the Coverage which is the focus for adjudication. The Coverage against which the claim is to be adjudicated focal : boolean [1..1] Reference to the program or plan identification, underwriter or payor coverage : Reference [1..1] « Coverage » The contract number of a business agreement which describes the terms and conditions businessArrangement : string [0..1] The relationship of the patient to the subscriber relationship : Coding [1..1] « The code for the relationship of the patient to the subscriber. (Strength=Example) Surface ?? » A list of references from the Insurer to which these services pertain preAuthRef : string [0..*] The Coverages adjudication details claimResponse : Reference [0..1] « ClaimResponse » The style (standard) and version of the original material which was converted into this resource originalRuleset : Coding [0..1] « The static and dynamic model to which contents conform, which may be business version or standard/version. (Strength=Example) Ruleset ?? » The adjudications adjudication results adjudication [0..*] The adjudications results adjudication [0..*] The adjudications results adjudication [0..*] The third tier service adjudications for submitted services subDetail [0..*] The second tier service adjudications for submitted services detail [0..*] The first tier service adjudications for submitted services item [0..*] The adjudications results adjudication [0..*] The adjudications results adjudication [0..*] The second tier service adjudications for payor added services detail [0..*] The first tier service adjudications for payor added services addItem [0..*] Mutually exclusive with Services Provided (Item) error [0..*] Payment details for the claim if the claim has been paid payment [0..1] Note text note processNote [0..*] Financial instrument by which payment information for health care coverage insurance [0..*]

XML Template 

<

<ClaimResponse xmlns="http://hl7.org/fhir"> doco

 <!-- from Resource: id, meta, implicitRules, and language -->
 <!-- from DomainResource: text, contained, extension, and modifierExtension -->
 <</identifier>
 <</request>
 <</ruleset>
 <</originalRuleset>
 <
 <</organization>
 <</requestProvider>
 <</requestOrganization>
 <
 <
 <</payeeType>
 <
  <
  <
  <
   <</code>
   <</amount>
   <

 <identifier><!-- 0..* Identifier Response  number --></identifier>
 <status value="[code]"/><!-- 0..1 active | cancelled | draft | entered-in-error -->
 <patient><!-- 0..1 Reference(Patient) The subject of the Products and Services --></patient>
 <created value="[dateTime]"/><!-- 0..1 Creation date -->
 <insurer><!-- 0..1 Reference(Organization) Insurance issuing organization --></insurer>
 <requestProvider><!-- 0..1 Reference(Practitioner) Responsible practitioner --></requestProvider>
 <requestOrganization><!-- 0..1 Reference(Organization) Responsible organization --></requestOrganization>
 <request><!-- 0..1 Reference(Claim) Id of resource triggering adjudication --></request>
 <outcome><!-- 0..1 CodeableConcept complete | error | partial --></outcome>
 <disposition value="[string]"/><!-- 0..1 Disposition Message -->
 <payeeType><!-- 0..1 CodeableConcept Party to be paid any benefits payable --></payeeType>
 <item>  <!-- 0..* Line items -->
  <sequenceLinkId value="[positiveInt]"/><!-- 1..1 Service instance -->
  <noteNumber value="[positiveInt]"/><!-- 0..* List of note numbers which apply -->
  <adjudication>  <!-- 0..* Adjudication details -->
   <category><!-- 1..1 CodeableConcept Adjudication category such as co-pay, eligible, benefit, etc. --></category>
   <reason><!-- 0..1 CodeableConcept Explanation of Adjudication outcome --></reason>
   <amount><!-- 0..1 Money Monetary amount --></amount>
   <value value="[decimal]"/><!-- 0..1 Non-monetary value -->

  </adjudication>
  <
   <
   <
    <</code>
    <</amount>
    <
   </adjudication>
   <
    <
    <
     <</code>
     <</amount>
     <
    </adjudication>

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

   </subDetail>
  </detail>
 </item>
 <
  <
  <</service>
  <</fee>
  <
  <
   <</code>
   <</amount>
   <
  </adjudication>
  <
   <</service>
   <</fee>
   <
    <</code>
    <</amount>
    <
   </adjudication>

 <addItem>  <!-- 0..* Insurer added line items -->
  <sequenceLinkId value="[positiveInt]"/><!-- 0..* Service instances -->
  <revenue><!-- 0..1 CodeableConcept Revenue or cost center code --></revenue>
  <category><!-- 0..1 CodeableConcept Type of service or product --></category>
  <service><!-- 0..1 CodeableConcept Group, Service or Product --></service>
  <modifier><!-- 0..* CodeableConcept Service/Product billing modifiers --></modifier>
  <fee><!-- 0..1 Money Professional fee or Product charge --></fee>
  <noteNumber value="[positiveInt]"/><!-- 0..* List of note numbers which apply -->
  <adjudication><!-- 0..* Content as for ClaimResponse.item.adjudication Added items adjudication --></adjudication>
  <detail>  <!-- 0..* Added items details -->
   <revenue><!-- 0..1 CodeableConcept Revenue or cost center code --></revenue>
   <category><!-- 0..1 CodeableConcept Type of service or product --></category>
   <service><!-- 0..1 CodeableConcept Service or Product --></service>
   <modifier><!-- 0..* CodeableConcept Service/Product billing modifiers --></modifier>
   <fee><!-- 0..1 Money Professional fee or Product charge --></fee>
   <noteNumber value="[positiveInt]"/><!-- 0..* List of note numbers which apply -->
   <adjudication><!-- 0..* Content as for ClaimResponse.item.adjudication Added items detail adjudication --></adjudication>

  </detail>
 </addItem>
 <
  <
  <
  <
  <</code>

 <error>  <!-- 0..* Processing errors -->
  <sequenceLinkId value="[positiveInt]"/><!-- 0..1 Item sequence number -->
  <detailSequenceLinkId value="[positiveInt]"/><!-- 0..1 Detail sequence number -->
  <subdetailSequenceLinkId value="[positiveInt]"/><!-- 0..1 Subdetail sequence number -->
  <code><!-- 1..1 CodeableConcept Error code detailing processing issues --></code>

 </error>
 <</totalCost>
 <</unallocDeductable>
 <</totalBenefit>
 <</paymentAdjustment>
 <</paymentAdjustmentReason>
 <
 <</paymentAmount>
 <</paymentRef>
 <</reserved>
 <</form>
 <
  <
  <</type>
  <
 </note>
 <
  <
  <
  <</coverage>
  <
  <</relationship>
  <
  <</claimResponse>
  <</originalRuleset>
 </coverage>

 <totalCost><!-- 0..1 Money Total Cost of service from the Claim --></totalCost>
 <unallocDeductable><!-- 0..1 Money Unallocated deductible --></unallocDeductable>
 <totalBenefit><!-- 0..1 Money Total benefit payable for the Claim --></totalBenefit>
 <payment>  <!-- 0..1 Payment details, if paid -->
  <type><!-- 0..1 CodeableConcept Partial or Complete --></type>
  <adjustment><!-- 0..1 Money Payment adjustment for non-Claim issues --></adjustment>
  <adjustmentReason><!-- 0..1 CodeableConcept Explanation for the non-claim adjustment --></adjustmentReason>
  <date value="[date]"/><!-- 0..1 Expected data of Payment -->
  <amount><!-- 0..1 Money Payable amount after adjustment --></amount>
  <identifier><!-- 0..1 Identifier Identifier of the payment instrument --></identifier>
 </payment>
 <reserved><!-- 0..1 Coding Funds reserved status --></reserved>
 <form><!-- 0..1 CodeableConcept Printed Form Identifier --></form>
 <processNote>  <!-- 0..* Processing notes -->
  <number value="[positiveInt]"/><!-- 0..1 Sequence Number for this note -->
  <type><!-- 0..1 CodeableConcept display | print | printoper --></type>
  <text value="[string]"/><!-- 0..1 Note explanatory text -->
  <language><!-- 0..1 CodeableConcept Language if different from the resource --></language>
 </processNote>
 <communicationRequest><!-- 0..* Reference(CommunicationRequest) Request for additional information --></communicationRequest>
 <insurance>  <!-- 0..* Insurance or medical plan -->
  <sequence value="[positiveInt]"/><!-- 1..1 Service instance identifier -->
  <focal value="[boolean]"/><!-- 1..1 Is the focal Coverage -->
  <coverage><!-- 1..1 Reference(Coverage) Insurance information --></coverage>
  <businessArrangement value="[string]"/><!-- 0..1 Business agreement -->
  <preAuthRef value="[string]"/><!-- 0..* Pre-Authorization/Determination Reference -->
  <claimResponse><!-- 0..1 Reference(ClaimResponse) Adjudication results --></claimResponse>
 </insurance>

</ClaimResponse>

JSON Template 

{
  "resourceType" : "",

{doco
  "resourceType" : "ClaimResponse",

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

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

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

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

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

  "addItem" : [{ // Insurer added line items
    "sequenceLinkId" : ["<positiveInt>"], // Service instances
    "revenue" : { CodeableConcept }, // Revenue or cost center code
    "category" : { CodeableConcept }, // Type of service or product
    "service" : { CodeableConcept }, // Group, Service or Product
    "modifier" : [{ CodeableConcept }], // Service/Product billing modifiers
    "fee" : { Money }, // Professional fee or Product charge
    "noteNumber" : ["<positiveInt>"], // List of note numbers which apply
    "adjudication" : [{ Content as for ClaimResponse.item.adjudication }], // Added items adjudication
    "detail" : [{ // Added items details
      "revenue" : { CodeableConcept }, // Revenue or cost center code
      "category" : { CodeableConcept }, // Type of service or product
      "service" : { CodeableConcept }, // Service or Product
      "modifier" : [{ CodeableConcept }], // Service/Product billing modifiers
      "fee" : { Money }, // Professional fee or Product charge
      "noteNumber" : ["<positiveInt>"], // List of note numbers which apply
      "adjudication" : [{ Content as for ClaimResponse.item.adjudication }] // Added items detail adjudication

    }]
  }],
  "
    "
    "
    "
    "

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

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

  "totalCost" : { Money }, // Total Cost of service from the Claim
  "unallocDeductable" : { Money }, // Unallocated deductible
  "totalBenefit" : { Money }, // Total benefit payable for the Claim
  "payment" : { // Payment details, if paid
    "type" : { CodeableConcept }, // Partial or Complete
    "adjustment" : { Money }, // Payment adjustment for non-Claim issues
    "adjustmentReason" : { CodeableConcept }, // Explanation for the non-claim adjustment
    "date" : "<date>", // Expected data of Payment
    "amount" : { Money }, // Payable amount after adjustment
    "identifier" : { Identifier } // Identifier of the payment instrument
  },
  "reserved" : { Coding }, // Funds reserved status
  "form" : { CodeableConcept }, // Printed Form Identifier
  "processNote" : [{ // Processing notes
    "number" : "<positiveInt>", // Sequence Number for this note
    "type" : { CodeableConcept }, // display | print | printoper
    "text" : "<string>", // Note explanatory text
    "language" : { CodeableConcept } // Language if different from the resource

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

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

  }]
}

Turtle Template 


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


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

  # from Resource: .id, .meta, .implicitRules, and .language
  # from DomainResource: .text, .contained, .extension, and .modifierExtension
  fhir:ClaimResponse.identifier [ Identifier ], ... ; # 0..* Response  number
  fhir:ClaimResponse.status [ code ]; # 0..1 active | cancelled | draft | entered-in-error
  fhir:ClaimResponse.patient [ Reference(Patient) ]; # 0..1 The subject of the Products and Services
  fhir:ClaimResponse.created [ dateTime ]; # 0..1 Creation date
  fhir:ClaimResponse.insurer [ Reference(Organization) ]; # 0..1 Insurance issuing organization
  fhir:ClaimResponse.requestProvider [ Reference(Practitioner) ]; # 0..1 Responsible practitioner
  fhir:ClaimResponse.requestOrganization [ Reference(Organization) ]; # 0..1 Responsible organization
  fhir:ClaimResponse.request [ Reference(Claim) ]; # 0..1 Id of resource triggering adjudication
  fhir:ClaimResponse.outcome [ CodeableConcept ]; # 0..1 complete | error | partial
  fhir:ClaimResponse.disposition [ string ]; # 0..1 Disposition Message
  fhir:ClaimResponse.payeeType [ CodeableConcept ]; # 0..1 Party to be paid any benefits payable
  fhir:ClaimResponse.item [ # 0..* Line items
    fhir:ClaimResponse.item.sequenceLinkId [ positiveInt ]; # 1..1 Service instance
    fhir:ClaimResponse.item.noteNumber [ positiveInt ], ... ; # 0..* List of note numbers which apply
    fhir:ClaimResponse.item.adjudication [ # 0..* Adjudication details
      fhir:ClaimResponse.item.adjudication.category [ CodeableConcept ]; # 1..1 Adjudication category such as co-pay, eligible, benefit, etc.
      fhir:ClaimResponse.item.adjudication.reason [ CodeableConcept ]; # 0..1 Explanation of Adjudication outcome
      fhir:ClaimResponse.item.adjudication.amount [ Money ]; # 0..1 Monetary amount
      fhir:ClaimResponse.item.adjudication.value [ decimal ]; # 0..1 Non-monetary value
    ], ...;
    fhir:ClaimResponse.item.detail [ # 0..* Detail line items
      fhir:ClaimResponse.item.detail.sequenceLinkId [ positiveInt ]; # 1..1 Service instance
      fhir:ClaimResponse.item.detail.noteNumber [ positiveInt ], ... ; # 0..* List of note numbers which apply
      fhir:ClaimResponse.item.detail.adjudication [ See ClaimResponse.item.adjudication ], ... ; # 0..* Detail level adjudication details
      fhir:ClaimResponse.item.detail.subDetail [ # 0..* Subdetail line items
        fhir:ClaimResponse.item.detail.subDetail.sequenceLinkId [ positiveInt ]; # 1..1 Service instance
        fhir:ClaimResponse.item.detail.subDetail.noteNumber [ positiveInt ], ... ; # 0..* List of note numbers which apply
        fhir:ClaimResponse.item.detail.subDetail.adjudication [ See ClaimResponse.item.adjudication ], ... ; # 0..* Subdetail level adjudication details
      ], ...;
    ], ...;
  ], ...;
  fhir:ClaimResponse.addItem [ # 0..* Insurer added line items
    fhir:ClaimResponse.addItem.sequenceLinkId [ positiveInt ], ... ; # 0..* Service instances
    fhir:ClaimResponse.addItem.revenue [ CodeableConcept ]; # 0..1 Revenue or cost center code
    fhir:ClaimResponse.addItem.category [ CodeableConcept ]; # 0..1 Type of service or product
    fhir:ClaimResponse.addItem.service [ CodeableConcept ]; # 0..1 Group, Service or Product
    fhir:ClaimResponse.addItem.modifier [ CodeableConcept ], ... ; # 0..* Service/Product billing modifiers
    fhir:ClaimResponse.addItem.fee [ Money ]; # 0..1 Professional fee or Product charge
    fhir:ClaimResponse.addItem.noteNumber [ positiveInt ], ... ; # 0..* List of note numbers which apply
    fhir:ClaimResponse.addItem.adjudication [ See ClaimResponse.item.adjudication ], ... ; # 0..* Added items adjudication
    fhir:ClaimResponse.addItem.detail [ # 0..* Added items details
      fhir:ClaimResponse.addItem.detail.revenue [ CodeableConcept ]; # 0..1 Revenue or cost center code
      fhir:ClaimResponse.addItem.detail.category [ CodeableConcept ]; # 0..1 Type of service or product
      fhir:ClaimResponse.addItem.detail.service [ CodeableConcept ]; # 0..1 Service or Product
      fhir:ClaimResponse.addItem.detail.modifier [ CodeableConcept ], ... ; # 0..* Service/Product billing modifiers
      fhir:ClaimResponse.addItem.detail.fee [ Money ]; # 0..1 Professional fee or Product charge
      fhir:ClaimResponse.addItem.detail.noteNumber [ positiveInt ], ... ; # 0..* List of note numbers which apply
      fhir:ClaimResponse.addItem.detail.adjudication [ See ClaimResponse.item.adjudication ], ... ; # 0..* Added items detail adjudication
    ], ...;
  ], ...;
  fhir:ClaimResponse.error [ # 0..* Processing errors
    fhir:ClaimResponse.error.sequenceLinkId [ positiveInt ]; # 0..1 Item sequence number
    fhir:ClaimResponse.error.detailSequenceLinkId [ positiveInt ]; # 0..1 Detail sequence number
    fhir:ClaimResponse.error.subdetailSequenceLinkId [ positiveInt ]; # 0..1 Subdetail sequence number
    fhir:ClaimResponse.error.code [ CodeableConcept ]; # 1..1 Error code detailing processing issues
  ], ...;
  fhir:ClaimResponse.totalCost [ Money ]; # 0..1 Total Cost of service from the Claim
  fhir:ClaimResponse.unallocDeductable [ Money ]; # 0..1 Unallocated deductible
  fhir:ClaimResponse.totalBenefit [ Money ]; # 0..1 Total benefit payable for the Claim
  fhir:ClaimResponse.payment [ # 0..1 Payment details, if paid
    fhir:ClaimResponse.payment.type [ CodeableConcept ]; # 0..1 Partial or Complete
    fhir:ClaimResponse.payment.adjustment [ Money ]; # 0..1 Payment adjustment for non-Claim issues
    fhir:ClaimResponse.payment.adjustmentReason [ CodeableConcept ]; # 0..1 Explanation for the non-claim adjustment
    fhir:ClaimResponse.payment.date [ date ]; # 0..1 Expected data of Payment
    fhir:ClaimResponse.payment.amount [ Money ]; # 0..1 Payable amount after adjustment
    fhir:ClaimResponse.payment.identifier [ Identifier ]; # 0..1 Identifier of the payment instrument
  ];
  fhir:ClaimResponse.reserved [ Coding ]; # 0..1 Funds reserved status
  fhir:ClaimResponse.form [ CodeableConcept ]; # 0..1 Printed Form Identifier
  fhir:ClaimResponse.processNote [ # 0..* Processing notes
    fhir:ClaimResponse.processNote.number [ positiveInt ]; # 0..1 Sequence Number for this note
    fhir:ClaimResponse.processNote.type [ CodeableConcept ]; # 0..1 display | print | printoper
    fhir:ClaimResponse.processNote.text [ string ]; # 0..1 Note explanatory text
    fhir:ClaimResponse.processNote.language [ CodeableConcept ]; # 0..1 Language if different from the resource
  ], ...;
  fhir:ClaimResponse.communicationRequest [ Reference(CommunicationRequest) ], ... ; # 0..* Request for additional information
  fhir:ClaimResponse.insurance [ # 0..* Insurance or medical plan
    fhir:ClaimResponse.insurance.sequence [ positiveInt ]; # 1..1 Service instance identifier
    fhir:ClaimResponse.insurance.focal [ boolean ]; # 1..1 Is the focal Coverage
    fhir:ClaimResponse.insurance.coverage [ Reference(Coverage) ]; # 1..1 Insurance information
    fhir:ClaimResponse.insurance.businessArrangement [ string ]; # 0..1 Business agreement
    fhir:ClaimResponse.insurance.preAuthRef [ string ], ... ; # 0..* Pre-Authorization/Determination Reference
    fhir:ClaimResponse.insurance.claimResponse [ Reference(ClaimResponse) ]; # 0..1 Adjudication results
  ], ...;
]

  Changes since DSTU2

ClaimResponse
ClaimResponse.status
  • Added Element
ClaimResponse.patient
  • Added Element
ClaimResponse.insurer
  • Added Element
ClaimResponse.outcome
  • Type changed from code to CodeableConcept
  • Remove Binding http://hl7.org/fhir/ValueSet/remittance-outcome (required)
ClaimResponse.payeeType
  • Type changed from Coding to CodeableConcept
ClaimResponse.item.adjudication.category
  • Added Element
ClaimResponse.item.adjudication.reason
  • Added Element
ClaimResponse.item.adjudication.amount
  • Type changed from Quantity{http://hl7.org/fhir/StructureDefinition/Money} to Money
ClaimResponse.item.detail.noteNumber
  • Added Element
ClaimResponse.item.detail.adjudication
  • Remove BackboneElement
ClaimResponse.item.detail.subDetail.noteNumber
  • Added Element
ClaimResponse.item.detail.subDetail.adjudication
  • Remove BackboneElement
ClaimResponse.addItem.revenue
  • Added Element
ClaimResponse.addItem.category
  • Added Element
ClaimResponse.addItem.service
  • Min Cardinality changed from 1 to 0
  • Type changed from Coding to CodeableConcept
ClaimResponse.addItem.modifier
  • Added Element
ClaimResponse.addItem.fee
  • Type changed from Quantity{http://hl7.org/fhir/StructureDefinition/Money} to Money
ClaimResponse.addItem.noteNumber
  • Added Element
ClaimResponse.addItem.adjudication
  • Remove BackboneElement
ClaimResponse.addItem.detail.revenue
  • Added Element
ClaimResponse.addItem.detail.category
  • Added Element
ClaimResponse.addItem.detail.service
  • Min Cardinality changed from 1 to 0
  • Type changed from Coding to CodeableConcept
ClaimResponse.addItem.detail.modifier
  • Added Element
ClaimResponse.addItem.detail.fee
  • Type changed from Quantity{http://hl7.org/fhir/StructureDefinition/Money} to Money
ClaimResponse.addItem.detail.noteNumber
  • Added Element
ClaimResponse.addItem.detail.adjudication
  • Remove BackboneElement
ClaimResponse.error.code
  • Type changed from Coding to CodeableConcept
  • Remove Binding http://hl7.org/fhir/ValueSet/adjudication-error (required)
ClaimResponse.totalCost
  • Type changed from Quantity{http://hl7.org/fhir/StructureDefinition/Money} to Money
ClaimResponse.unallocDeductable
  • Type changed from Quantity{http://hl7.org/fhir/StructureDefinition/Money} to Money
ClaimResponse.totalBenefit
  • Type changed from Quantity{http://hl7.org/fhir/StructureDefinition/Money} to Money
ClaimResponse.payment
  • Added Element
ClaimResponse.payment.type
  • Added Element
ClaimResponse.payment.adjustment
  • Added Element
ClaimResponse.payment.adjustmentReason
  • Added Element
ClaimResponse.payment.date
  • Added Element
ClaimResponse.payment.amount
  • Added Element
ClaimResponse.payment.identifier
  • Added Element
ClaimResponse.form
  • Type changed from Coding to CodeableConcept
  • Remove Binding http://hl7.org/fhir/ValueSet/forms (required)
ClaimResponse.processNote
  • Added Element
ClaimResponse.processNote.number
  • Added Element
ClaimResponse.processNote.type
  • Added Element
ClaimResponse.processNote.text
  • Added Element
ClaimResponse.processNote.language
  • Added Element
ClaimResponse.communicationRequest
  • Added Element
ClaimResponse.insurance
  • Added Element
ClaimResponse.insurance.sequence
  • Added Element
ClaimResponse.insurance.focal
  • Added Element
ClaimResponse.insurance.coverage
  • Added Element
ClaimResponse.insurance.businessArrangement
  • Added Element
ClaimResponse.insurance.preAuthRef
  • Added Element
ClaimResponse.insurance.claimResponse
  • Added Element
ClaimResponse.ruleset
  • deleted
ClaimResponse.originalRuleset
  • deleted
ClaimResponse.organization
  • deleted
ClaimResponse.item.adjudication.code
  • deleted
ClaimResponse.item.detail.adjudication.code
  • deleted
ClaimResponse.item.detail.adjudication.amount
  • deleted
ClaimResponse.item.detail.adjudication.value
  • deleted
ClaimResponse.item.detail.subDetail.adjudication.code
  • deleted
ClaimResponse.item.detail.subDetail.adjudication.amount
  • deleted
ClaimResponse.item.detail.subDetail.adjudication.value
  • deleted
ClaimResponse.addItem.noteNumberLinkId
  • deleted
ClaimResponse.addItem.adjudication.code
  • deleted
ClaimResponse.addItem.adjudication.amount
  • deleted
ClaimResponse.addItem.adjudication.value
  • deleted
ClaimResponse.addItem.detail.adjudication.code
  • deleted
ClaimResponse.addItem.detail.adjudication.amount
  • deleted
ClaimResponse.addItem.detail.adjudication.value
  • deleted
ClaimResponse.paymentAdjustment
  • deleted
ClaimResponse.paymentAdjustmentReason
  • deleted
ClaimResponse.paymentDate
  • deleted
ClaimResponse.paymentAmount
  • deleted
ClaimResponse.paymentRef
  • deleted
ClaimResponse.note
  • deleted
ClaimResponse.coverage
  • deleted

See the Full Difference for further information

This analysis is available as XML or JSON .

 

Alternate definitions: Schema / Schematron , Resource Profile Master Definition ( XML , JSON ), Questionnaire XML Schema / Schematron (for ) + JSON Schema , ShEx (for Turtle )

7.2.2.1 13.7.2.1 Terminology Bindings

ClaimResponse.ruleset ClaimResponse.originalRuleset ClaimResponse.coverage.originalRuleset ClaimResponse.item.adjudication.code ClaimResponse.item.detail.adjudication.code ClaimResponse.item.detail.subDetail.adjudication.code ClaimResponse.addItem.adjudication.code ClaimResponse.addItem.detail.adjudication.code ClaimResponse.paymentAdjustmentReason ClaimResponse.note.type ClaimResponse.coverage.relationship
Path Definition Type Reference
ClaimResponse.status The static and dynamic model to which contents conform, which may be business version or standard/version. A code specifying the state of the resource instance. Example Required Ruleset Financial Resource Status Codes
ClaimResponse.outcome The outcome result of the processing. claim processing Required Example RemittanceOutcome Claim Processing Codes
ClaimResponse.payeeType A code for the party to be reimbursed. Example Claim Payee Type Codes
ClaimResponse.item.adjudication.category The adjudication codes. Extensible Example Adjudication Value Codes
ClaimResponse.item.adjudication.reason The adjudication reason codes. Example Adjudication Reason Codes
ClaimResponse.addItem.revenue
ClaimResponse.addItem.detail.revenue 		Codes for the revenue or cost centers supplying the service and/or products. Example Example Revenue Center Codes
ClaimResponse.addItem.category
ClaimResponse.addItem.detail.category 		Benefit subcategories such as: oral-basic, major, glasses Example Benefit SubCategory Codes
ClaimResponse.addItem.service
ClaimResponse.addItem.detail.service 		Allowable service and product codes. Example USCLS Codes
ClaimResponse.addItem.modifier
ClaimResponse.addItem.detail.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. Example Modifier type Codes
ClaimResponse.error.code The error codes for adjudication processing. error codes. Required Example Adjudication Error Codes
ClaimResponse.payment.type The type (partial, complete) of the payment Example Example Payment Type Codes
ClaimResponse.payment.adjustmentReason Payment Adjustment reason codes. Extensible Example Payment Adjustment Reason Codes
ClaimResponse.reserved For whom funds are to be reserved: (Patient, Provider, None). Example Funds Reservation Codes
ClaimResponse.form The forms codes. Required Example Form Codes
ClaimResponse.processNote.type The presentation types of notes. Required NoteType
ClaimResponse.processNote.language The code for the relationship of the patient to the subscriber. A human language. Example Extensible , but limited to All Languages Surface Codes Common Languages

7.2.3 13.7.3 Search Parameters

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

Name Type Description Paths 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 insurer claimresponse ClaimResponse.identifier
insurer reference The organization who generated this resource ClaimResponse.insurer
( Organization )
outcome token The processing outcome ClaimResponse.outcome
patient reference The subject of care. ClaimResponse.patient
( Patient )
payment-date date The expected paymentDate ClaimResponse.payment.date
request reference The claim reference ClaimResponse.request
( Claim )
request-provider reference The Provider of the claim ClaimResponse.requestProvider
( Practitioner )