ClaimResponse

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

Schema

Elements

Name	Required	Type	Description
identifier		Identifier[]	Business Identifier for a claim response Details A unique identifier assigned to this claim response.
status	✓	code	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.
type	✓	CodeableConcept	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.
subType		CodeableConcept	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.
use	✓	code	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.
patient	✓	Reference<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.
created	✓	dateTime	Response creation date Details The date this resource was created.
insurer	✓	Reference<Organization>	Party responsible for reimbursement Details The party responsible for authorization, adjudication and reimbursement.
requestor		Reference< 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.
request		Reference<Claim>	Id of resource triggering adjudication Details Original request resource reference.
outcome	✓	code	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).
disposition		string	Disposition Message Details A human readable description of the status of the adjudication.
preAuthRef		string	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.
preAuthPeriod		Period	Preauthorization reference effective period Details The time frame during which this authorization is effective.
payeeType		CodeableConcept	Party to be paid any benefits payable Details Type of Party to be reimbursed: subscriber, provider, other.
item		ClaimResponseItem[]	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.
id		string	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.
extension		Extension[]	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.
modifierExtension		Extension[]	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.
itemSequence	✓	positiveInt	Claim item instance identifier Details A number to uniquely reference the claim item entries.
noteNumber		positiveInt[]	Applicable note numbers Details The numbers associated with notes below which apply to the adjudication of this item.
adjudication	✓	ClaimResponseItemAdjudication[]	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.
id		string	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.
extension		Extension[]	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.
modifierExtension		Extension[]	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.
category	✓	CodeableConcept	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.
reason		CodeableConcept	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.
amount		Money	Monetary amount Details Monetary amount associated with the category. For example: amount submitted, eligible amount, co-payment, and benefit payable.
value		decimal	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.
detail		ClaimResponseItemDetail[]	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.
id		string	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.
extension		Extension[]	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.
modifierExtension		Extension[]	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.
detailSequence	✓	positiveInt	Claim detail instance identifier Details A number to uniquely reference the claim detail entry.
noteNumber		positiveInt[]	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.
subDetail		ClaimResponseItemDetailSubDetail[]	Adjudication for claim sub-details Details A sub-detail adjudication of a simple product or service.
id		string	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.
extension		Extension[]	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.
modifierExtension		Extension[]	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.
subDetailSequence	✓	positiveInt	Claim sub-detail instance identifier Details A number to uniquely reference the claim sub-detail entry.
noteNumber		positiveInt[]	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.
addItem		ClaimResponseAddItem[]	Insurer added line items Details The first-tier service adjudications for payor added product or service lines.
id		string	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.
extension		Extension[]	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.
modifierExtension		Extension[]	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.
itemSequence		positiveInt[]	Item sequence number Details Claim items which this service line is intended to replace.
detailSequence		positiveInt[]	Detail sequence number Details The sequence number of the details within the claim item which this line is intended to replace.
subdetailSequence		positiveInt[]	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.
provider		Reference< Practitioner | PractitionerRole | Organization >[]	Authorized providers Details The providers who are authorized for the services rendered to the patient.
productOrService	✓	CodeableConcept	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'.
modifier		CodeableConcept[]	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.
programCode		CodeableConcept[]	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.
quantity		Quantity	Count of products or services Details The number of repetitions of a service or product.
unitPrice		Money	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.
factor		decimal	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).
net		Money	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.
bodySite		CodeableConcept	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.
subSite		CodeableConcept[]	Anatomical sub-location Details A region or surface of the bodySite, e.g. limb region or tooth surface(s).
noteNumber		positiveInt[]	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.
detail		ClaimResponseAddItemDetail[]	Insurer added line details Details The second-tier service adjudications for payor added services.
id		string	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.
extension		Extension[]	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.
modifierExtension		Extension[]	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.
productOrService	✓	CodeableConcept	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'.
modifier		CodeableConcept[]	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.
quantity		Quantity	Count of products or services Details The number of repetitions of a service or product.
unitPrice		Money	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.
factor		decimal	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).
net		Money	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.
noteNumber		positiveInt[]	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.
subDetail		ClaimResponseAddItemDetailSubDetail[]	Insurer added line items Details The third-tier service adjudications for payor added services.
id		string	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.
extension		Extension[]	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.
modifierExtension		Extension[]	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.
productOrService	✓	CodeableConcept	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'.
modifier		CodeableConcept[]	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.
quantity		Quantity	Count of products or services Details The number of repetitions of a service or product.
unitPrice		Money	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.
factor		decimal	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).
net		Money	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.
noteNumber		positiveInt[]	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.
total		ClaimResponseTotal[]	Adjudication totals Details Categorized monetary totals for the adjudication. Totals for amounts submitted, co-pays, benefits payable etc.
id		string	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.
extension		Extension[]	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.
modifierExtension		Extension[]	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.
category	✓	CodeableConcept	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.
amount	✓	Money	Financial total for the category Details Monetary total amount associated with the category.
payment		ClaimResponsePayment	Payment Details Details Payment details for the adjudication of the claim.
id		string	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.
extension		Extension[]	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.
modifierExtension		Extension[]	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.
type	✓	CodeableConcept	Partial or complete payment Details Whether this represents partial or complete payment of the benefits payable.
adjustment		Money	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.
adjustmentReason		CodeableConcept	Explanation for the adjustment Details Reason for the payment adjustment.
date		date	Expected date of payment Details Estimated date the payment will be issued or the actual issue date of payment.
amount	✓	Money	Payable amount after adjustment Details Benefits payable less any payment adjustment.
identifier		Identifier	Business identifier for the payment Details Issuer's unique identifier for the payment instrument. For example: EFT number or check number.
fundsReserve		CodeableConcept	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.
formCode		CodeableConcept	Printed form identifier Details A code for the form to be used for printing the content. May be needed to identify specific jurisdictional forms.
form		Attachment	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.
processNote		ClaimResponseProcessNote[]	Note concerning adjudication Details A note that describes or explains adjudication results in a human readable form.
id		string	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.
extension		Extension[]	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.
modifierExtension		Extension[]	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.
number		positiveInt	Note instance identifier Details A number to uniquely identify a note entry.
type		code	display | print | printoper Details The business purpose of the note text.
text	✓	string	Note explanatory text Details The explanation or description associated with the processing.
language		CodeableConcept	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.
communicationRequest		Reference<CommunicationRequest>[]	Request for additional information Details Request for additional supporting or authorizing information. For example: professional reports, documents, images, clinical resources, or accident reports.
insurance		ClaimResponseInsurance[]	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.
id		string	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.
extension		Extension[]	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.
modifierExtension		Extension[]	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.
sequence	✓	positiveInt	Insurance instance identifier Details A number to uniquely identify insurance entries and provide a sequence of coverages to convey coordination of benefit order.
focal	✓	boolean	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.
coverage	✓	Reference<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.
businessArrangement		string	Additional provider contract number Details A business agreement number established between the provider and the insurer for special business processing purposes.
claimResponse		Reference<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.
error		ClaimResponseError[]	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.
id		string	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.
extension		Extension[]	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.
modifierExtension		Extension[]	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.
itemSequence		positiveInt	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.
detailSequence		positiveInt	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.
subDetailSequence		positiveInt	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.
code	✓	CodeableConcept	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

Name	Type	Description	Expression
created	date	The creation date	ClaimResponse.created
disposition	string	The contents of the disposition message	ClaimResponse.disposition
identifier	token	The identity of the ClaimResponse	ClaimResponse.identifier
insurer	reference	The organization which generated this resource	ClaimResponse.insurer
outcome	token	The processing outcome	ClaimResponse.outcome
patient	reference	The subject of care	ClaimResponse.patient
payment-date	date	The expected payment date	ClaimResponse.payment.date
request	reference	The claim reference	ClaimResponse.request
requestor	reference	The Provider of the claim	ClaimResponse.requestor
status	token	The status of the ClaimResponse	ClaimResponse.status
use	token	The type of claim	ClaimResponse.use

Inherited Elements

Name	Required	Type	Description
id		string	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.
meta		Meta	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.
implicitRules		uri	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.
language		code	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).
text		Narrative	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.
contained		Resource[]	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.
extension		Extension[]	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.
modifierExtension		Extension[]	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.

Usage

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

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

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

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

Additional Information

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

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

Relationships

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

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

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

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

The eClaim domain includes a number of related resources

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

Referenced By

• Claim
• DeviceRequest
• ExplanationOfBenefit
• MedicationRequest
• ServiceRequest
• Task