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ClaimResponse

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

Properties

NameRequiredTypeDescription
identifierIdentifier[]

Business Identifier for a claim response

Details

A unique identifier assigned to this claim response.

statuscode

active | cancelled | draft | entered-in-error

Details

The status of the resource instance.

This element is labeled as a modifier because the status contains codes that mark the resource as not currently valid.

typeCodeableConcept

More granular claim type

Details

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

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

subTypeCodeableConcept

More granular claim type

Details

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

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

usecode

claim | preauthorization | predetermination

Details

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

patientReference<Patient>

The recipient of the products and services

Details

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

createddateTime

Response creation date

Details

The date this resource was created.

insurerReference<Organization>

Party responsible for reimbursement

Details

The party responsible for authorization, adjudication and reimbursement.

requestorReference< Practitioner | PractitionerRole | Organization >

Party responsible for the claim

Details

The provider which is responsible for the claim, predetermination or preauthorization.

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

requestReference<Claim>

Id of resource triggering adjudication

Details

Original request resource reference.

outcomecode

queued | complete | error | partial

Details

The outcome of the claim, predetermination, or preauthorization processing.

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

dispositionstring

Disposition Message

Details

A human readable description of the status of the adjudication.

preAuthRefstring

Preauthorization reference

Details

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

This value is only present on preauthorization adjudications.

preAuthPeriodPeriod

Preauthorization reference effective period

Details

The time frame during which this authorization is effective.

payeeTypeCodeableConcept

Party to be paid any benefits payable

Details

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

itemClaimResponseItem[]

Adjudication for claim line items

Details

A claim line. Either a simple (a product or service) or a 'group' of details which can also be a simple items or groups of sub-details.

idstring

Unique id for inter-element referencing

Details

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

extensionExtension[]

Additional content defined by implementations

Details

May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

modifierExtensionExtension[]

Extensions that cannot be ignored even if unrecognized

Details

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

itemSequencepositiveInt

Claim item instance identifier

Details

A number to uniquely reference the claim item entries.

noteNumberpositiveInt[]

Applicable note numbers

Details

The numbers associated with notes below which apply to the adjudication of this item.

adjudicationClaimResponseItemAdjudication[]

Adjudication details

Details

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

idstring

Unique id for inter-element referencing

Details

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

extensionExtension[]

Additional content defined by implementations

Details

May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

modifierExtensionExtension[]

Extensions that cannot be ignored even if unrecognized

Details

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

categoryCodeableConcept

Type of adjudication information

Details

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

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

reasonCodeableConcept

Explanation of adjudication outcome

Details

A code supporting the understanding of the adjudication result and explaining variance from expected amount.

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

amountMoney

Monetary amount

Details

Monetary amount associated with the category.

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

valuedecimal

Non-monetary value

Details

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

For example: eligible percentage or co-payment percentage.

detailClaimResponseItemDetail[]

Adjudication for claim details

Details

A claim detail. Either a simple (a product or service) or a 'group' of sub-details which are simple items.

idstring

Unique id for inter-element referencing

Details

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

extensionExtension[]

Additional content defined by implementations

Details

May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

modifierExtensionExtension[]

Extensions that cannot be ignored even if unrecognized

Details

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

detailSequencepositiveInt

Claim detail instance identifier

Details

A number to uniquely reference the claim detail entry.

noteNumberpositiveInt[]

Applicable note numbers

Details

The numbers associated with notes below which apply to the adjudication of this item.

adjudication[]

Detail level adjudication details

Details

The adjudication results.

subDetailClaimResponseItemDetailSubDetail[]

Adjudication for claim sub-details

Details

A sub-detail adjudication of a simple product or service.

idstring

Unique id for inter-element referencing

Details

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

extensionExtension[]

Additional content defined by implementations

Details

May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

modifierExtensionExtension[]

Extensions that cannot be ignored even if unrecognized

Details

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

subDetailSequencepositiveInt

Claim sub-detail instance identifier

Details

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

noteNumberpositiveInt[]

Applicable note numbers

Details

The numbers associated with notes below which apply to the adjudication of this item.

adjudication[]

Subdetail level adjudication details

Details

The adjudication results.

addItemClaimResponseAddItem[]

Insurer added line items

Details

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

idstring

Unique id for inter-element referencing

Details

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

extensionExtension[]

Additional content defined by implementations

Details

May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

modifierExtensionExtension[]

Extensions that cannot be ignored even if unrecognized

Details

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

itemSequencepositiveInt[]

Item sequence number

Details

Claim items which this service line is intended to replace.

detailSequencepositiveInt[]

Detail sequence number

Details

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

subdetailSequencepositiveInt[]

Subdetail sequence number

Details

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

providerReference< Practitioner | PractitionerRole | Organization >[]

Authorized providers

Details

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

productOrServiceCodeableConcept

Billing, service, product, or drug code

Details

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

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

modifierCodeableConcept[]

Service/Product billing modifiers

Details

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

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

programCodeCodeableConcept[]

Program the product or service is provided under

Details

Identifies the program under which this may be recovered.

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

serviced[x]date, Period

Date or dates of service or product delivery

Details

The date or dates when the service or product was supplied, performed or completed.

location[x]CodeableConcept, Address, Reference<Location>

Place of service or where product was supplied

Details

Where the product or service was provided.

quantityQuantity

Count of products or services

Details

The number of repetitions of a service or product.

unitPriceMoney

Fee, charge or cost per item

Details

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

factordecimal

Price scaling factor

Details

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

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

netMoney

Total item cost

Details

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

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

bodySiteCodeableConcept

Anatomical location

Details

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

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

subSiteCodeableConcept[]

Anatomical sub-location

Details

A region or surface of the bodySite, e.g. limb region or tooth surface(s).

noteNumberpositiveInt[]

Applicable note numbers

Details

The numbers associated with notes below which apply to the adjudication of this item.

adjudication[]

Added items adjudication

Details

The adjudication results.

detailClaimResponseAddItemDetail[]

Insurer added line details

Details

The second-tier service adjudications for payor added services.

idstring

Unique id for inter-element referencing

Details

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

extensionExtension[]

Additional content defined by implementations

Details

May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

modifierExtensionExtension[]

Extensions that cannot be ignored even if unrecognized

Details

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

productOrServiceCodeableConcept

Billing, service, product, or drug code

Details

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

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

modifierCodeableConcept[]

Service/Product billing modifiers

Details

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

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

quantityQuantity

Count of products or services

Details

The number of repetitions of a service or product.

unitPriceMoney

Fee, charge or cost per item

Details

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

factordecimal

Price scaling factor

Details

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

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

netMoney

Total item cost

Details

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

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

noteNumberpositiveInt[]

Applicable note numbers

Details

The numbers associated with notes below which apply to the adjudication of this item.

adjudication[]

Added items detail adjudication

Details

The adjudication results.

subDetailClaimResponseAddItemDetailSubDetail[]

Insurer added line items

Details

The third-tier service adjudications for payor added services.

idstring

Unique id for inter-element referencing

Details

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

extensionExtension[]

Additional content defined by implementations

Details

May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

modifierExtensionExtension[]

Extensions that cannot be ignored even if unrecognized

Details

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

productOrServiceCodeableConcept

Billing, service, product, or drug code

Details

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

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

modifierCodeableConcept[]

Service/Product billing modifiers

Details

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

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

quantityQuantity

Count of products or services

Details

The number of repetitions of a service or product.

unitPriceMoney

Fee, charge or cost per item

Details

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

factordecimal

Price scaling factor

Details

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

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

netMoney

Total item cost

Details

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

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

noteNumberpositiveInt[]

Applicable note numbers

Details

The numbers associated with notes below which apply to the adjudication of this item.

adjudication[]

Added items detail adjudication

Details

The adjudication results.

adjudication[]

Header-level adjudication

Details

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

totalClaimResponseTotal[]

Adjudication totals

Details

Categorized monetary totals for the adjudication.

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

idstring

Unique id for inter-element referencing

Details

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

extensionExtension[]

Additional content defined by implementations

Details

May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

modifierExtensionExtension[]

Extensions that cannot be ignored even if unrecognized

Details

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

categoryCodeableConcept

Type of adjudication information

Details

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

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

amountMoney

Financial total for the category

Details

Monetary total amount associated with the category.

paymentClaimResponsePayment

Payment Details

Details

Payment details for the adjudication of the claim.

idstring

Unique id for inter-element referencing

Details

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

extensionExtension[]

Additional content defined by implementations

Details

May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

modifierExtensionExtension[]

Extensions that cannot be ignored even if unrecognized

Details

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

typeCodeableConcept

Partial or complete payment

Details

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

adjustmentMoney

Payment adjustment for non-claim issues

Details

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

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

adjustmentReasonCodeableConcept

Explanation for the adjustment

Details

Reason for the payment adjustment.

datedate

Expected date of payment

Details

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

amountMoney

Payable amount after adjustment

Details

Benefits payable less any payment adjustment.

identifierIdentifier

Business identifier for the payment

Details

Issuer's unique identifier for the payment instrument.

For example: EFT number or check number.

fundsReserveCodeableConcept

Funds reserved status

Details

A code, used only on a response to a preauthorization, to indicate whether the benefits payable have been reserved and for whom.

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

formCodeCodeableConcept

Printed form identifier

Details

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

May be needed to identify specific jurisdictional forms.

formAttachment

Printed reference or actual form

Details

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

Needed to permit insurers to include the actual form.

processNoteClaimResponseProcessNote[]

Note concerning adjudication

Details

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

idstring

Unique id for inter-element referencing

Details

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

extensionExtension[]

Additional content defined by implementations

Details

May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

modifierExtensionExtension[]

Extensions that cannot be ignored even if unrecognized

Details

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

numberpositiveInt

Note instance identifier

Details

A number to uniquely identify a note entry.

typecode

display | print | printoper

Details

The business purpose of the note text.

textstring

Note explanatory text

Details

The explanation or description associated with the processing.

languageCodeableConcept

Language of the text

Details

A code to define the language used in the text of the note.

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

communicationRequestReference<CommunicationRequest>[]

Request for additional information

Details

Request for additional supporting or authorizing information.

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

insuranceClaimResponseInsurance[]

Patient insurance information

Details

Financial instruments for reimbursement for the health care products and services specified on the claim.

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

idstring

Unique id for inter-element referencing

Details

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

extensionExtension[]

Additional content defined by implementations

Details

May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

modifierExtensionExtension[]

Extensions that cannot be ignored even if unrecognized

Details

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

sequencepositiveInt

Insurance instance identifier

Details

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

focalboolean

Coverage to be used for adjudication

Details

A flag to indicate that this Coverage is to be used for adjudication of this claim when set to true.

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

coverageReference<Coverage>

Insurance information

Details

Reference to the insurance card level information contained in the Coverage resource. The coverage issuing insurer will use these details to locate the patient's actual coverage within the insurer's information system.

businessArrangementstring

Additional provider contract number

Details

A business agreement number established between the provider and the insurer for special business processing purposes.

claimResponseReference<ClaimResponse>

Adjudication results

Details

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

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

errorClaimResponseError[]

Processing errors

Details

Errors encountered during the processing of the adjudication.

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

idstring

Unique id for inter-element referencing

Details

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

extensionExtension[]

Additional content defined by implementations

Details

May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

modifierExtensionExtension[]

Extensions that cannot be ignored even if unrecognized

Details

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

itemSequencepositiveInt

Item sequence number

Details

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

detailSequencepositiveInt

Detail sequence number

Details

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

subDetailSequencepositiveInt

Subdetail sequence number

Details

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

codeCodeableConcept

Error code detailing processing issues

Details

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

Search Parameters

NameTypeDescriptionExpression
createddateThe creation dateClaimResponse.created
dispositionstringThe contents of the disposition messageClaimResponse.disposition
identifiertokenThe identity of the ClaimResponseClaimResponse.identifier
insurerreferenceThe organization which generated this resourceClaimResponse.insurer
outcometokenThe processing outcomeClaimResponse.outcome
patientreferenceThe subject of careClaimResponse.patient
payment-datedateThe expected payment dateClaimResponse.payment.date
requestreferenceThe claim referenceClaimResponse.request
requestorreferenceThe Provider of the claimClaimResponse.requestor
statustokenThe status of the ClaimResponseClaimResponse.status
usetokenThe type of claimClaimResponse.use

Inherited Properties

NameRequiredTypeDescription
idstring

Logical id of this artifact

Details

The logical id of the resource, as used in the URL for the resource. Once assigned, this value never changes.

The only time that a resource does not have an id is when it is being submitted to the server using a create operation.

metaMeta

Metadata about the resource

Details

The metadata about the resource. This is content that is maintained by the infrastructure. Changes to the content might not always be associated with version changes to the resource.

implicitRulesuri

A set of rules under which this content was created

Details

A reference to a set of rules that were followed when the resource was constructed, and which must be understood when processing the content. Often, this is a reference to an implementation guide that defines the special rules along with other profiles etc.

Asserting this rule set restricts the content to be only understood by a limited set of trading partners. This inherently limits the usefulness of the data in the long term. However, the existing health eco-system is highly fractured, and not yet ready to define, collect, and exchange data in a generally computable sense. Wherever possible, implementers and/or specification writers should avoid using this element. Often, when used, the URL is a reference to an implementation guide that defines these special rules as part of it's narrative along with other profiles, value sets, etc.

languagecode

Language of the resource content

Details

The base language in which the resource is written.

Language is provided to support indexing and accessibility (typically, services such as text to speech use the language tag). The html language tag in the narrative applies to the narrative. The language tag on the resource may be used to specify the language of other presentations generated from the data in the resource. Not all the content has to be in the base language. The Resource.language should not be assumed to apply to the narrative automatically. If a language is specified, it should it also be specified on the div element in the html (see rules in HTML5 for information about the relationship between xml:lang and the html lang attribute).

textNarrative

Text summary of the resource, for human interpretation

Details

A human-readable narrative that contains a summary of the resource and can be used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative. Resource definitions may define what content should be represented in the narrative to ensure clinical safety.

Contained resources do not have narrative. Resources that are not contained SHOULD have a narrative. In some cases, a resource may only have text with little or no additional discrete data (as long as all minOccurs=1 elements are satisfied). This may be necessary for data from legacy systems where information is captured as a "text blob" or where text is additionally entered raw or narrated and encoded information is added later.

containedResource[]

Contained, inline Resources

Details

These resources do not have an independent existence apart from the resource that contains them - they cannot be identified independently, and nor can they have their own independent transaction scope.

This should never be done when the content can be identified properly, as once identification is lost, it is extremely difficult (and context dependent) to restore it again. Contained resources may have profiles and tags In their meta elements, but SHALL NOT have security labels.

extensionExtension[]

Additional content defined by implementations

Details

May be used to represent additional information that is not part of the basic definition of the resource. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

modifierExtensionExtension[]

Extensions that cannot be ignored

Details

May be used to represent additional information that is not part of the basic definition of the resource and that modifies the understanding of the element that contains it and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.