Release 4

This page is part of the FHIR Specification (v4.0.1: R4 - Mixed Normative and STU) in it's permanent home (it will always be available at this URL). The current version which supercedes this version is 5.0.0. For a full list of available versions, see the Directory of published versions . Page versions: R5 R4B R4 R3 R2

13.7 Resource ClaimResponse - Content

Financial Management

Work Group

Maturity Level: 2

Trial Use

Security Category: Patient

Compartments: Patient, Practitioner

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

13.7.1 Scope and Usage

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

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

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

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

13.7.1.1 Additional Information

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

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

13.7.2 Boundaries and Relationships

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

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

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

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

The eClaim domain includes a number of related resources

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

This resource is referenced by Claim, itself, DeviceRequest, ExplanationOfBenefit, MedicationRequest, ServiceRequest and Task

Structure

Name	Flags	Card.	Type	Description & Constraints
ClaimResponse	TU		DomainResource	Response to a claim predetermination or preauthorization Elements defined in Ancestors: id, meta, implicitRules, language, text, contained, extension, modifierExtension
identifier		0..*	Identifier	Business Identifier for a claim response
status	?!Σ	1..1	code	active \| cancelled \| draft \| entered-in-error Financial Resource Status Codes (Required)
type	Σ	1..1	CodeableConcept	More granular claim type Claim Type Codes (Extensible)
subType		0..1	CodeableConcept	More granular claim type Example Claim SubType Codes (Example)
use	Σ	1..1	code	claim \| preauthorization \| predetermination Use (Required)
patient	Σ	1..1	Reference(Patient)	The recipient of the products and services
created	Σ	1..1	dateTime	Response creation date
insurer	Σ	1..1	Reference(Organization)	Party responsible for reimbursement
requestor		0..1	Reference(Practitioner \| PractitionerRole \| Organization)	Party responsible for the claim
request	Σ	0..1	Reference(Claim)	Id of resource triggering adjudication
outcome	Σ	1..1	code	queued \| complete \| error \| partial Claim Processing Codes (Required)
disposition		0..1	string	Disposition Message
preAuthRef		0..1	string	Preauthorization reference
preAuthPeriod		0..1	Period	Preauthorization reference effective period
payeeType		0..1	CodeableConcept	Party to be paid any benefits payable PayeeType (Example)
item		0..*	BackboneElement	Adjudication for claim line items
itemSequence		1..1	positiveInt	Claim item instance identifier
noteNumber		0..*	positiveInt	Applicable note numbers
adjudication		1..*	BackboneElement	Adjudication details
category		1..1	CodeableConcept	Type of adjudication information Adjudication Value Codes (Example)
reason		0..1	CodeableConcept	Explanation of adjudication outcome Adjudication Reason Codes (Example)
amount		0..1	Money	Monetary amount
value		0..1	decimal	Non-monetary value
detail		0..*	BackboneElement	Adjudication for claim details
detailSequence		1..1	positiveInt	Claim detail instance identifier
noteNumber		0..*	positiveInt	Applicable note numbers
adjudication		1..*	see adjudication	Detail level adjudication details
subDetail		0..*	BackboneElement	Adjudication for claim sub-details
subDetailSequence		1..1	positiveInt	Claim sub-detail instance identifier
noteNumber		0..*	positiveInt	Applicable note numbers
adjudication		0..*	see adjudication	Subdetail level adjudication details
addItem		0..*	BackboneElement	Insurer added line items
itemSequence		0..*	positiveInt	Item sequence number
detailSequence		0..*	positiveInt	Detail sequence number
subdetailSequence		0..*	positiveInt	Subdetail sequence number
provider		0..*	Reference(Practitioner \| PractitionerRole \| Organization)	Authorized providers
productOrService		1..1	CodeableConcept	Billing, service, product, or drug code USCLS Codes (Example)
modifier		0..*	CodeableConcept	Service/Product billing modifiers Modifier type Codes (Example)
programCode		0..*	CodeableConcept	Program the product or service is provided under Example Program Reason Codes (Example)
serviced[x]		0..1		Date or dates of service or product delivery
servicedDate			date
servicedPeriod			Period
location[x]		0..1		Place of service or where product was supplied Example Service Place Codes (Example)
locationCodeableConcept			CodeableConcept
locationAddress			Address
locationReference			Reference(Location)
quantity		0..1	SimpleQuantity	Count of products or services
unitPrice		0..1	Money	Fee, charge or cost per item
factor		0..1	decimal	Price scaling factor
net		0..1	Money	Total item cost
bodySite		0..1	CodeableConcept	Anatomical location Oral Site Codes (Example)
subSite		0..*	CodeableConcept	Anatomical sub-location Surface Codes (Example)
noteNumber		0..*	positiveInt	Applicable note numbers
adjudication		1..*	see adjudication	Added items adjudication
detail		0..*	BackboneElement	Insurer added line details
productOrService		1..1	CodeableConcept	Billing, service, product, or drug code USCLS Codes (Example)
modifier		0..*	CodeableConcept	Service/Product billing modifiers Modifier type Codes (Example)
quantity		0..1	SimpleQuantity	Count of products or services
unitPrice		0..1	Money	Fee, charge or cost per item
factor		0..1	decimal	Price scaling factor
net		0..1	Money	Total item cost
noteNumber		0..*	positiveInt	Applicable note numbers
adjudication		1..*	see adjudication	Added items detail adjudication
subDetail		0..*	BackboneElement	Insurer added line items
productOrService		1..1	CodeableConcept	Billing, service, product, or drug code USCLS Codes (Example)
modifier		0..*	CodeableConcept	Service/Product billing modifiers Modifier type Codes (Example)
quantity		0..1	SimpleQuantity	Count of products or services
unitPrice		0..1	Money	Fee, charge or cost per item
factor		0..1	decimal	Price scaling factor
net		0..1	Money	Total item cost
noteNumber		0..*	positiveInt	Applicable note numbers
adjudication		1..*	see adjudication	Added items detail adjudication
adjudication		0..*	see adjudication	Header-level adjudication
total	Σ	0..*	BackboneElement	Adjudication totals
category	Σ	1..1	CodeableConcept	Type of adjudication information Adjudication Value Codes (Example)
amount	Σ	1..1	Money	Financial total for the category
payment		0..1	BackboneElement	Payment Details
type		1..1	CodeableConcept	Partial or complete payment Example Payment Type Codes (Example)
adjustment		0..1	Money	Payment adjustment for non-claim issues
adjustmentReason		0..1	CodeableConcept	Explanation for the adjustment Payment Adjustment Reason Codes (Example)
date		0..1	date	Expected date of payment
amount		1..1	Money	Payable amount after adjustment
identifier		0..1	Identifier	Business identifier for the payment
fundsReserve		0..1	CodeableConcept	Funds reserved status FundsReserve (Example)
formCode		0..1	CodeableConcept	Printed form identifier Forms (Example)
form		0..1	Attachment	Printed reference or actual form
processNote		0..*	BackboneElement	Note concerning adjudication
number		0..1	positiveInt	Note instance identifier
type		0..1	code	display \| print \| printoper NoteType (Required)
text		1..1	string	Note explanatory text
language		0..1	CodeableConcept	Language of the text Common Languages (Preferred but limited to AllLanguages)
communicationRequest		0..*	Reference(CommunicationRequest)	Request for additional information
insurance		0..*	BackboneElement	Patient insurance information
sequence		1..1	positiveInt	Insurance instance identifier
focal		1..1	boolean	Coverage to be used for adjudication
coverage		1..1	Reference(Coverage)	Insurance information
businessArrangement		0..1	string	Additional provider contract number
claimResponse		0..1	Reference(ClaimResponse)	Adjudication results
error		0..*	BackboneElement	Processing errors
itemSequence		0..1	positiveInt	Item sequence number
detailSequence		0..1	positiveInt	Detail sequence number
subDetailSequence		0..1	positiveInt	Subdetail sequence number
code		1..1	CodeableConcept	Error code detailing processing issues AdjudicationError (Example)
Documentation for this format

UML Diagram (Legend)

XML Template

<ClaimResponse xmlns="http://hl7.org/fhir"> 
 <!-- from Resource: id, meta, implicitRules, and language -->
 <!-- from DomainResource: text, contained, extension, and modifierExtension -->
 <identifier><!-- 0..* Identifier Business Identifier for a claim response --></identifier>
 <status value="[code]"/><!-- 1..1 active | cancelled | draft | entered-in-error -->
 <type><!-- 1..1 CodeableConcept More granular claim type --></type>
 <subType><!-- 0..1 CodeableConcept More granular claim type --></subType>
 <use value="[code]"/><!-- 1..1 claim | preauthorization | predetermination -->
 <patient><!-- 1..1 Reference(Patient) The recipient of the products and services --></patient>
 <created value="[dateTime]"/><!-- 1..1 Response creation date -->
 <insurer><!-- 1..1 Reference(Organization) Party responsible for reimbursement --></insurer>
 <requestor><!-- 0..1 Reference(Practitioner|PractitionerRole|Organization) Party responsible for the claim --></requestor>
 <request><!-- 0..1 Reference(Claim) Id of resource triggering adjudication --></request>
 <outcome value="[code]"/><!-- 1..1 queued | complete | error | partial -->
 <disposition value="[string]"/><!-- 0..1 Disposition Message -->
 <preAuthRef value="[string]"/><!-- 0..1 Preauthorization reference -->
 <preAuthPeriod><!-- 0..1 Period Preauthorization reference effective period --></preAuthPeriod>
 <payeeType><!-- 0..1 CodeableConcept Party to be paid any benefits payable --></payeeType>
 <item>  <!-- 0..* Adjudication for claim line items -->
  <itemSequence value="[positiveInt]"/><!-- 1..1 Claim item instance identifier -->
  <noteNumber value="[positiveInt]"/><!-- 0..* Applicable note numbers -->
  <adjudication>  <!-- 1..* Adjudication details -->
   <category><!-- 1..1 CodeableConcept Type of adjudication information --></category>
   <reason><!-- 0..1 CodeableConcept Explanation of adjudication outcome --></reason>
   <amount><!-- 0..1 Money Monetary amount --></amount>
   <value value="[decimal]"/><!-- 0..1 Non-monetary value -->
  </adjudication>
  <detail>  <!-- 0..* Adjudication for claim details -->
   <detailSequence value="[positiveInt]"/><!-- 1..1 Claim detail instance identifier -->
   <noteNumber value="[positiveInt]"/><!-- 0..* Applicable note numbers -->
   <adjudication><!-- 1..* Content as for ClaimResponse.item.adjudication Detail level adjudication details --></adjudication>
   <subDetail>  <!-- 0..* Adjudication for claim sub-details -->
    <subDetailSequence value="[positiveInt]"/><!-- 1..1 Claim sub-detail instance identifier -->
    <noteNumber value="[positiveInt]"/><!-- 0..* Applicable note numbers -->
    <adjudication><!-- 0..* Content as for ClaimResponse.item.adjudication Subdetail level adjudication details --></adjudication>
   </subDetail>
  </detail>
 </item>
 <addItem>  <!-- 0..* Insurer added line items -->
  <itemSequence value="[positiveInt]"/><!-- 0..* Item sequence number -->
  <detailSequence value="[positiveInt]"/><!-- 0..* Detail sequence number -->
  <subdetailSequence value="[positiveInt]"/><!-- 0..* Subdetail sequence number -->
  <provider><!-- 0..* Reference(Practitioner|PractitionerRole|Organization) Authorized providers --></provider>
  <productOrService><!-- 1..1 CodeableConcept Billing, service, product, or drug code --></productOrService>
  <modifier><!-- 0..* CodeableConcept Service/Product billing modifiers --></modifier>
  <programCode><!-- 0..* CodeableConcept Program the product or service is provided under --></programCode>
  <serviced[x]><!-- 0..1 date|Period Date or dates of service or product delivery --></serviced[x]>
  <location[x]><!-- 0..1 CodeableConcept|Address|Reference(Location) Place of service or where product was supplied --></location[x]>
  <quantity><!-- 0..1 Quantity(SimpleQuantity) Count of products or services --></quantity>
  <unitPrice><!-- 0..1 Money Fee, charge or cost per item --></unitPrice>
  <factor value="[decimal]"/><!-- 0..1 Price scaling factor -->
  <net><!-- 0..1 Money Total item cost --></net>
  <bodySite><!-- 0..1 CodeableConcept Anatomical location --></bodySite>
  <subSite><!-- 0..* CodeableConcept Anatomical sub-location --></subSite>
  <noteNumber value="[positiveInt]"/><!-- 0..* Applicable note numbers -->
  <adjudication><!-- 1..* Content as for ClaimResponse.item.adjudication Added items adjudication --></adjudication>
  <detail>  <!-- 0..* Insurer added line details -->
   <productOrService><!-- 1..1 CodeableConcept Billing, service, product, or drug code --></productOrService>
   <modifier><!-- 0..* CodeableConcept Service/Product billing modifiers --></modifier>
   <quantity><!-- 0..1 Quantity(SimpleQuantity) Count of products or services --></quantity>
   <unitPrice><!-- 0..1 Money Fee, charge or cost per item --></unitPrice>
   <factor value="[decimal]"/><!-- 0..1 Price scaling factor -->
   <net><!-- 0..1 Money Total item cost --></net>
   <noteNumber value="[positiveInt]"/><!-- 0..* Applicable note numbers -->
   <adjudication><!-- 1..* Content as for ClaimResponse.item.adjudication Added items detail adjudication --></adjudication>
   <subDetail>  <!-- 0..* Insurer added line items -->
    <productOrService><!-- 1..1 CodeableConcept Billing, service, product, or drug code --></productOrService>
    <modifier><!-- 0..* CodeableConcept Service/Product billing modifiers --></modifier>
    <quantity><!-- 0..1 Quantity(SimpleQuantity) Count of products or services --></quantity>
    <unitPrice><!-- 0..1 Money Fee, charge or cost per item --></unitPrice>
    <factor value="[decimal]"/><!-- 0..1 Price scaling factor -->
    <net><!-- 0..1 Money Total item cost --></net>
    <noteNumber value="[positiveInt]"/><!-- 0..* Applicable note numbers -->
    <adjudication><!-- 1..* Content as for ClaimResponse.item.adjudication Added items detail adjudication --></adjudication>
   </subDetail>
  </detail>
 </addItem>
 <adjudication><!-- 0..* Content as for ClaimResponse.item.adjudication Header-level adjudication --></adjudication>
 <total>  <!-- 0..* Adjudication totals -->
  <category><!-- 1..1 CodeableConcept Type of adjudication information --></category>
  <amount><!-- 1..1 Money Financial total for the category --></amount>
 </total>
 <payment>  <!-- 0..1 Payment Details -->
  <type><!-- 1..1 CodeableConcept Partial or complete payment --></type>
  <adjustment><!-- 0..1 Money Payment adjustment for non-claim issues --></adjustment>
  <adjustmentReason><!-- 0..1 CodeableConcept Explanation for the adjustment --></adjustmentReason>
  <date value="[date]"/><!-- 0..1 Expected date of payment -->
  <amount><!-- 1..1 Money Payable amount after adjustment --></amount>
  <identifier><!-- 0..1 Identifier Business identifier for the payment --></identifier>
 </payment>
 <fundsReserve><!-- 0..1 CodeableConcept Funds reserved status --></fundsReserve>
 <formCode><!-- 0..1 CodeableConcept Printed form identifier --></formCode>
 <form><!-- 0..1 Attachment Printed reference or actual form --></form>
 <processNote>  <!-- 0..* Note concerning adjudication -->
  <number value="[positiveInt]"/><!-- 0..1 Note instance identifier -->
  <type value="[code]"/><!-- 0..1 display | print | printoper -->
  <text value="[string]"/><!-- 1..1 Note explanatory text -->
  <language><!-- 0..1 CodeableConcept Language of the text --></language>
 </processNote>
 <communicationRequest><!-- 0..* Reference(CommunicationRequest) Request for additional information --></communicationRequest>
 <insurance>  <!-- 0..* Patient insurance information -->
  <sequence value="[positiveInt]"/><!-- 1..1 Insurance instance identifier -->
  <focal value="[boolean]"/><!-- 1..1 Coverage to be used for adjudication -->
  <coverage><!-- 1..1 Reference(Coverage) Insurance information --></coverage>
  <businessArrangement value="[string]"/><!-- 0..1 Additional provider contract number -->
  <claimResponse><!-- 0..1 Reference(ClaimResponse) Adjudication results --></claimResponse>
 </insurance>
 <error>  <!-- 0..* Processing errors -->
  <itemSequence value="[positiveInt]"/><!-- 0..1 Item sequence number -->
  <detailSequence value="[positiveInt]"/><!-- 0..1 Detail sequence number -->
  <subDetailSequence value="[positiveInt]"/><!-- 0..1 Subdetail sequence number -->
  <code><!-- 1..1 CodeableConcept Error code detailing processing issues --></code>
 </error>
</ClaimResponse>

JSON Template

{
  "resourceType" : "ClaimResponse",
  // from Resource: id, meta, implicitRules, and language
  // from DomainResource: text, contained, extension, and modifierExtension
  "identifier" : [{ Identifier }], // Business Identifier for a claim response
  "status" : "<code>", // R!  active | cancelled | draft | entered-in-error
  "type" : { CodeableConcept }, // R!  More granular claim type
  "subType" : { CodeableConcept }, // More granular claim type
  "use" : "<code>", // R!  claim | preauthorization | predetermination
  "patient" : { Reference(Patient) }, // R!  The recipient of the products and services
  "created" : "<dateTime>", // R!  Response creation date
  "insurer" : { Reference(Organization) }, // R!  Party responsible for reimbursement
  "requestor" : { Reference(Practitioner|PractitionerRole|Organization) }, // Party responsible for the claim
  "request" : { Reference(Claim) }, // Id of resource triggering adjudication
  "outcome" : "<code>", // R!  queued | complete | error | partial
  "disposition" : "<string>", // Disposition Message
  "preAuthRef" : "<string>", // Preauthorization reference
  "preAuthPeriod" : { Period }, // Preauthorization reference effective period
  "payeeType" : { CodeableConcept }, // Party to be paid any benefits payable
  "item" : [{ // Adjudication for claim line items
    "itemSequence" : "<positiveInt>", // R!  Claim item instance identifier
    "noteNumber" : ["<positiveInt>"], // Applicable note numbers
    "adjudication" : [{ // R!  Adjudication details
      "category" : { CodeableConcept }, // R!  Type of adjudication information
      "reason" : { CodeableConcept }, // Explanation of adjudication outcome
      "amount" : { Money }, // Monetary amount
      "value" : <decimal> // Non-monetary value
    }],
    "detail" : [{ // Adjudication for claim details
      "detailSequence" : "<positiveInt>", // R!  Claim detail instance identifier
      "noteNumber" : ["<positiveInt>"], // Applicable note numbers
      "adjudication" : [{ Content as for ClaimResponse.item.adjudication }], // R!  Detail level adjudication details
      "subDetail" : [{ // Adjudication for claim sub-details
        "subDetailSequence" : "<positiveInt>", // R!  Claim sub-detail instance identifier
        "noteNumber" : ["<positiveInt>"], // Applicable note numbers
        "adjudication" : [{ Content as for ClaimResponse.item.adjudication }] // Subdetail level adjudication details
      }]
    }]
  }],
  "addItem" : [{ // Insurer added line items
    "itemSequence" : ["<positiveInt>"], // Item sequence number
    "detailSequence" : ["<positiveInt>"], // Detail sequence number
    "subdetailSequence" : ["<positiveInt>"], // Subdetail sequence number
    "provider" : [{ Reference(Practitioner|PractitionerRole|Organization) }], // Authorized providers
    "productOrService" : { CodeableConcept }, // R!  Billing, service, product, or drug code
    "modifier" : [{ CodeableConcept }], // Service/Product billing modifiers
    "programCode" : [{ CodeableConcept }], // Program the product or service is provided under
    // serviced[x]: Date or dates of service or product delivery. One of these 2:
    "servicedDate" : "<date>",
    "servicedPeriod" : { Period },
    // location[x]: Place of service or where product was supplied. One of these 3:
    "locationCodeableConcept" : { CodeableConcept },
    "locationAddress" : { Address },
    "locationReference" : { Reference(Location) },
    "quantity" : { Quantity(SimpleQuantity) }, // Count of products or services
    "unitPrice" : { Money }, // Fee, charge or cost per item
    "factor" : <decimal>, // Price scaling factor
    "net" : { Money }, // Total item cost
    "bodySite" : { CodeableConcept }, // Anatomical location
    "subSite" : [{ CodeableConcept }], // Anatomical sub-location
    "noteNumber" : ["<positiveInt>"], // Applicable note numbers
    "adjudication" : [{ Content as for ClaimResponse.item.adjudication }], // R!  Added items adjudication
    "detail" : [{ // Insurer added line details
      "productOrService" : { CodeableConcept }, // R!  Billing, service, product, or drug code
      "modifier" : [{ CodeableConcept }], // Service/Product billing modifiers
      "quantity" : { Quantity(SimpleQuantity) }, // Count of products or services
      "unitPrice" : { Money }, // Fee, charge or cost per item
      "factor" : <decimal>, // Price scaling factor
      "net" : { Money }, // Total item cost
      "noteNumber" : ["<positiveInt>"], // Applicable note numbers
      "adjudication" : [{ Content as for ClaimResponse.item.adjudication }], // R!  Added items detail adjudication
      "subDetail" : [{ // Insurer added line items
        "productOrService" : { CodeableConcept }, // R!  Billing, service, product, or drug code
        "modifier" : [{ CodeableConcept }], // Service/Product billing modifiers
        "quantity" : { Quantity(SimpleQuantity) }, // Count of products or services
        "unitPrice" : { Money }, // Fee, charge or cost per item
        "factor" : <decimal>, // Price scaling factor
        "net" : { Money }, // Total item cost
        "noteNumber" : ["<positiveInt>"], // Applicable note numbers
        "adjudication" : [{ Content as for ClaimResponse.item.adjudication }] // R!  Added items detail adjudication
      }]
    }]
  }],
  "adjudication" : [{ Content as for ClaimResponse.item.adjudication }], // Header-level adjudication
  "total" : [{ // Adjudication totals
    "category" : { CodeableConcept }, // R!  Type of adjudication information
    "amount" : { Money } // R!  Financial total for the category
  }],
  "payment" : { // Payment Details
    "type" : { CodeableConcept }, // R!  Partial or complete payment
    "adjustment" : { Money }, // Payment adjustment for non-claim issues
    "adjustmentReason" : { CodeableConcept }, // Explanation for the adjustment
    "date" : "<date>", // Expected date of payment
    "amount" : { Money }, // R!  Payable amount after adjustment
    "identifier" : { Identifier } // Business identifier for the payment
  },
  "fundsReserve" : { CodeableConcept }, // Funds reserved status
  "formCode" : { CodeableConcept }, // Printed form identifier
  "form" : { Attachment }, // Printed reference or actual form
  "processNote" : [{ // Note concerning adjudication
    "number" : "<positiveInt>", // Note instance identifier
    "type" : "<code>", // display | print | printoper
    "text" : "<string>", // R!  Note explanatory text
    "language" : { CodeableConcept } // Language of the text
  }],
  "communicationRequest" : [{ Reference(CommunicationRequest) }], // Request for additional information
  "insurance" : [{ // Patient insurance information
    "sequence" : "<positiveInt>", // R!  Insurance instance identifier
    "focal" : <boolean>, // R!  Coverage to be used for adjudication
    "coverage" : { Reference(Coverage) }, // R!  Insurance information
    "businessArrangement" : "<string>", // Additional provider contract number
    "claimResponse" : { Reference(ClaimResponse) } // Adjudication results
  }],
  "error" : [{ // Processing errors
    "itemSequence" : "<positiveInt>", // Item sequence number
    "detailSequence" : "<positiveInt>", // Detail sequence number
    "subDetailSequence" : "<positiveInt>", // Subdetail sequence number
    "code" : { CodeableConcept } // R!  Error code detailing processing issues
  }]
}

Turtle Template

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


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

  # from Resource: .id, .meta, .implicitRules, and .language
  # from DomainResource: .text, .contained, .extension, and .modifierExtension
  fhir:ClaimResponse.identifier [ Identifier ], ... ; # 0..* Business Identifier for a claim response
  fhir:ClaimResponse.status [ code ]; # 1..1 active | cancelled | draft | entered-in-error
  fhir:ClaimResponse.type [ CodeableConcept ]; # 1..1 More granular claim type
  fhir:ClaimResponse.subType [ CodeableConcept ]; # 0..1 More granular claim type
  fhir:ClaimResponse.use [ code ]; # 1..1 claim | preauthorization | predetermination
  fhir:ClaimResponse.patient [ Reference(Patient) ]; # 1..1 The recipient of the products and services
  fhir:ClaimResponse.created [ dateTime ]; # 1..1 Response creation date
  fhir:ClaimResponse.insurer [ Reference(Organization) ]; # 1..1 Party responsible for reimbursement
  fhir:ClaimResponse.requestor [ Reference(Practitioner|PractitionerRole|Organization) ]; # 0..1 Party responsible for the claim
  fhir:ClaimResponse.request [ Reference(Claim) ]; # 0..1 Id of resource triggering adjudication
  fhir:ClaimResponse.outcome [ code ]; # 1..1 queued | complete | error | partial
  fhir:ClaimResponse.disposition [ string ]; # 0..1 Disposition Message
  fhir:ClaimResponse.preAuthRef [ string ]; # 0..1 Preauthorization reference
  fhir:ClaimResponse.preAuthPeriod [ Period ]; # 0..1 Preauthorization reference effective period
  fhir:ClaimResponse.payeeType [ CodeableConcept ]; # 0..1 Party to be paid any benefits payable
  fhir:ClaimResponse.item [ # 0..* Adjudication for claim line items
    fhir:ClaimResponse.item.itemSequence [ positiveInt ]; # 1..1 Claim item instance identifier
    fhir:ClaimResponse.item.noteNumber [ positiveInt ], ... ; # 0..* Applicable note numbers
    fhir:ClaimResponse.item.adjudication [ # 1..* Adjudication details
      fhir:ClaimResponse.item.adjudication.category [ CodeableConcept ]; # 1..1 Type of adjudication information
      fhir:ClaimResponse.item.adjudication.reason [ CodeableConcept ]; # 0..1 Explanation of adjudication outcome
      fhir:ClaimResponse.item.adjudication.amount [ Money ]; # 0..1 Monetary amount
      fhir:ClaimResponse.item.adjudication.value [ decimal ]; # 0..1 Non-monetary value
    ], ...;
    fhir:ClaimResponse.item.detail [ # 0..* Adjudication for claim details
      fhir:ClaimResponse.item.detail.detailSequence [ positiveInt ]; # 1..1 Claim detail instance identifier
      fhir:ClaimResponse.item.detail.noteNumber [ positiveInt ], ... ; # 0..* Applicable note numbers
      fhir:ClaimResponse.item.detail.adjudication [ See ClaimResponse.item.adjudication ], ... ; # 1..* Detail level adjudication details
      fhir:ClaimResponse.item.detail.subDetail [ # 0..* Adjudication for claim sub-details
        fhir:ClaimResponse.item.detail.subDetail.subDetailSequence [ positiveInt ]; # 1..1 Claim sub-detail instance identifier
        fhir:ClaimResponse.item.detail.subDetail.noteNumber [ positiveInt ], ... ; # 0..* Applicable note numbers
        fhir:ClaimResponse.item.detail.subDetail.adjudication [ See ClaimResponse.item.adjudication ], ... ; # 0..* Subdetail level adjudication details
      ], ...;
    ], ...;
  ], ...;
  fhir:ClaimResponse.addItem [ # 0..* Insurer added line items
    fhir:ClaimResponse.addItem.itemSequence [ positiveInt ], ... ; # 0..* Item sequence number
    fhir:ClaimResponse.addItem.detailSequence [ positiveInt ], ... ; # 0..* Detail sequence number
    fhir:ClaimResponse.addItem.subdetailSequence [ positiveInt ], ... ; # 0..* Subdetail sequence number
    fhir:ClaimResponse.addItem.provider [ Reference(Practitioner|PractitionerRole|Organization) ], ... ; # 0..* Authorized providers
    fhir:ClaimResponse.addItem.productOrService [ CodeableConcept ]; # 1..1 Billing, service, product, or drug code
    fhir:ClaimResponse.addItem.modifier [ CodeableConcept ], ... ; # 0..* Service/Product billing modifiers
    fhir:ClaimResponse.addItem.programCode [ CodeableConcept ], ... ; # 0..* Program the product or service is provided under
    # ClaimResponse.addItem.serviced[x] : 0..1 Date or dates of service or product delivery. One of these 2
      fhir:ClaimResponse.addItem.servicedDate [ date ]
      fhir:ClaimResponse.addItem.servicedPeriod [ Period ]
    # ClaimResponse.addItem.location[x] : 0..1 Place of service or where product was supplied. One of these 3
      fhir:ClaimResponse.addItem.locationCodeableConcept [ CodeableConcept ]
      fhir:ClaimResponse.addItem.locationAddress [ Address ]
      fhir:ClaimResponse.addItem.locationReference [ Reference(Location) ]
    fhir:ClaimResponse.addItem.quantity [ Quantity(SimpleQuantity) ]; # 0..1 Count of products or services
    fhir:ClaimResponse.addItem.unitPrice [ Money ]; # 0..1 Fee, charge or cost per item
    fhir:ClaimResponse.addItem.factor [ decimal ]; # 0..1 Price scaling factor
    fhir:ClaimResponse.addItem.net [ Money ]; # 0..1 Total item cost
    fhir:ClaimResponse.addItem.bodySite [ CodeableConcept ]; # 0..1 Anatomical location
    fhir:ClaimResponse.addItem.subSite [ CodeableConcept ], ... ; # 0..* Anatomical sub-location
    fhir:ClaimResponse.addItem.noteNumber [ positiveInt ], ... ; # 0..* Applicable note numbers
    fhir:ClaimResponse.addItem.adjudication [ See ClaimResponse.item.adjudication ], ... ; # 1..* Added items adjudication
    fhir:ClaimResponse.addItem.detail [ # 0..* Insurer added line details
      fhir:ClaimResponse.addItem.detail.productOrService [ CodeableConcept ]; # 1..1 Billing, service, product, or drug code
      fhir:ClaimResponse.addItem.detail.modifier [ CodeableConcept ], ... ; # 0..* Service/Product billing modifiers
      fhir:ClaimResponse.addItem.detail.quantity [ Quantity(SimpleQuantity) ]; # 0..1 Count of products or services
      fhir:ClaimResponse.addItem.detail.unitPrice [ Money ]; # 0..1 Fee, charge or cost per item
      fhir:ClaimResponse.addItem.detail.factor [ decimal ]; # 0..1 Price scaling factor
      fhir:ClaimResponse.addItem.detail.net [ Money ]; # 0..1 Total item cost
      fhir:ClaimResponse.addItem.detail.noteNumber [ positiveInt ], ... ; # 0..* Applicable note numbers
      fhir:ClaimResponse.addItem.detail.adjudication [ See ClaimResponse.item.adjudication ], ... ; # 1..* Added items detail adjudication
      fhir:ClaimResponse.addItem.detail.subDetail [ # 0..* Insurer added line items
        fhir:ClaimResponse.addItem.detail.subDetail.productOrService [ CodeableConcept ]; # 1..1 Billing, service, product, or drug code
        fhir:ClaimResponse.addItem.detail.subDetail.modifier [ CodeableConcept ], ... ; # 0..* Service/Product billing modifiers
        fhir:ClaimResponse.addItem.detail.subDetail.quantity [ Quantity(SimpleQuantity) ]; # 0..1 Count of products or services
        fhir:ClaimResponse.addItem.detail.subDetail.unitPrice [ Money ]; # 0..1 Fee, charge or cost per item
        fhir:ClaimResponse.addItem.detail.subDetail.factor [ decimal ]; # 0..1 Price scaling factor
        fhir:ClaimResponse.addItem.detail.subDetail.net [ Money ]; # 0..1 Total item cost
        fhir:ClaimResponse.addItem.detail.subDetail.noteNumber [ positiveInt ], ... ; # 0..* Applicable note numbers
        fhir:ClaimResponse.addItem.detail.subDetail.adjudication [ See ClaimResponse.item.adjudication ], ... ; # 1..* Added items detail adjudication
      ], ...;
    ], ...;
  ], ...;
  fhir:ClaimResponse.adjudication [ See ClaimResponse.item.adjudication ], ... ; # 0..* Header-level adjudication
  fhir:ClaimResponse.total [ # 0..* Adjudication totals
    fhir:ClaimResponse.total.category [ CodeableConcept ]; # 1..1 Type of adjudication information
    fhir:ClaimResponse.total.amount [ Money ]; # 1..1 Financial total for the category
  ], ...;
  fhir:ClaimResponse.payment [ # 0..1 Payment Details
    fhir:ClaimResponse.payment.type [ CodeableConcept ]; # 1..1 Partial or complete payment
    fhir:ClaimResponse.payment.adjustment [ Money ]; # 0..1 Payment adjustment for non-claim issues
    fhir:ClaimResponse.payment.adjustmentReason [ CodeableConcept ]; # 0..1 Explanation for the adjustment
    fhir:ClaimResponse.payment.date [ date ]; # 0..1 Expected date of payment
    fhir:ClaimResponse.payment.amount [ Money ]; # 1..1 Payable amount after adjustment
    fhir:ClaimResponse.payment.identifier [ Identifier ]; # 0..1 Business identifier for the payment
  ];
  fhir:ClaimResponse.fundsReserve [ CodeableConcept ]; # 0..1 Funds reserved status
  fhir:ClaimResponse.formCode [ CodeableConcept ]; # 0..1 Printed form identifier
  fhir:ClaimResponse.form [ Attachment ]; # 0..1 Printed reference or actual form
  fhir:ClaimResponse.processNote [ # 0..* Note concerning adjudication
    fhir:ClaimResponse.processNote.number [ positiveInt ]; # 0..1 Note instance identifier
    fhir:ClaimResponse.processNote.type [ code ]; # 0..1 display | print | printoper
    fhir:ClaimResponse.processNote.text [ string ]; # 1..1 Note explanatory text
    fhir:ClaimResponse.processNote.language [ CodeableConcept ]; # 0..1 Language of the text
  ], ...;
  fhir:ClaimResponse.communicationRequest [ Reference(CommunicationRequest) ], ... ; # 0..* Request for additional information
  fhir:ClaimResponse.insurance [ # 0..* Patient insurance information
    fhir:ClaimResponse.insurance.sequence [ positiveInt ]; # 1..1 Insurance instance identifier
    fhir:ClaimResponse.insurance.focal [ boolean ]; # 1..1 Coverage to be used for adjudication
    fhir:ClaimResponse.insurance.coverage [ Reference(Coverage) ]; # 1..1 Insurance information
    fhir:ClaimResponse.insurance.businessArrangement [ string ]; # 0..1 Additional provider contract number
    fhir:ClaimResponse.insurance.claimResponse [ Reference(ClaimResponse) ]; # 0..1 Adjudication results
  ], ...;
  fhir:ClaimResponse.error [ # 0..* Processing errors
    fhir:ClaimResponse.error.itemSequence [ positiveInt ]; # 0..1 Item sequence number
    fhir:ClaimResponse.error.detailSequence [ positiveInt ]; # 0..1 Detail sequence number
    fhir:ClaimResponse.error.subDetailSequence [ positiveInt ]; # 0..1 Subdetail sequence number
    fhir:ClaimResponse.error.code [ CodeableConcept ]; # 1..1 Error code detailing processing issues
  ], ...;
]

Changes since R3

ClaimResponse

ClaimResponse.status

Min Cardinality changed from 0 to 1
Change value set from http://hl7.org/fhir/ValueSet/fm-status to http://hl7.org/fhir/ValueSet/fm-status|4.0.1

ClaimResponse.type

Added Mandatory Element

ClaimResponse.subType

Added Element

ClaimResponse.use

Added Mandatory Element

ClaimResponse.patient

Min Cardinality changed from 0 to 1

ClaimResponse.created

Min Cardinality changed from 0 to 1

ClaimResponse.insurer

Min Cardinality changed from 0 to 1

ClaimResponse.requestor

Renamed from requestProvider to requestor
Type Reference: Added Target Types PractitionerRole, Organization

ClaimResponse.outcome

Min Cardinality changed from 0 to 1
Type changed from CodeableConcept to code
Add Binding http://hl7.org/fhir/ValueSet/remittance-outcome|4.0.1 (required)

ClaimResponse.preAuthRef

Moved from ClaimResponse.insurance to ClaimResponse
Max Cardinality changed from * to 1

ClaimResponse.preAuthPeriod

Added Element

ClaimResponse.item.itemSequence

Renamed from sequenceLinkId to itemSequence

ClaimResponse.item.adjudication

Min Cardinality changed from 0 to 1

ClaimResponse.item.detail.detailSequence

Renamed from sequenceLinkId to detailSequence

ClaimResponse.item.detail.adjudication

Min Cardinality changed from 0 to 1

ClaimResponse.item.detail.subDetail.subDetailSequence

Renamed from sequenceLinkId to subDetailSequence

ClaimResponse.addItem.itemSequence

Renamed from sequenceLinkId to itemSequence

ClaimResponse.addItem.detailSequence

Added Element

ClaimResponse.addItem.subdetailSequence

Added Element

ClaimResponse.addItem.provider

Added Element

ClaimResponse.addItem.productOrService

Renamed from service to productOrService
Min Cardinality changed from 0 to 1

ClaimResponse.addItem.programCode

Added Element

ClaimResponse.addItem.serviced[x]

Added Element

ClaimResponse.addItem.location[x]

Added Element

ClaimResponse.addItem.quantity

Added Element

ClaimResponse.addItem.unitPrice

Added Element

ClaimResponse.addItem.factor

Added Element

ClaimResponse.addItem.net

Added Element

ClaimResponse.addItem.bodySite

Added Element

ClaimResponse.addItem.subSite

Added Element

ClaimResponse.addItem.adjudication

Min Cardinality changed from 0 to 1

ClaimResponse.addItem.detail.productOrService

Renamed from service to productOrService
Min Cardinality changed from 0 to 1

ClaimResponse.addItem.detail.quantity

Added Element

ClaimResponse.addItem.detail.unitPrice

Added Element

ClaimResponse.addItem.detail.factor

Added Element

ClaimResponse.addItem.detail.net

Added Element

ClaimResponse.addItem.detail.adjudication

Min Cardinality changed from 0 to 1

ClaimResponse.addItem.detail.subDetail

Added Element

ClaimResponse.addItem.detail.subDetail.productOrService

Added Mandatory Element

ClaimResponse.addItem.detail.subDetail.modifier

Added Element

ClaimResponse.addItem.detail.subDetail.quantity

Added Element

ClaimResponse.addItem.detail.subDetail.unitPrice

Added Element

ClaimResponse.addItem.detail.subDetail.factor

Added Element

ClaimResponse.addItem.detail.subDetail.net

Added Element

ClaimResponse.addItem.detail.subDetail.noteNumber

Added Element

ClaimResponse.addItem.detail.subDetail.adjudication

Added Mandatory Element

ClaimResponse.adjudication

Added Element

ClaimResponse.total

Added Element

ClaimResponse.total.category

Added Mandatory Element

ClaimResponse.total.amount

Added Mandatory Element

ClaimResponse.payment.type

Min Cardinality changed from 0 to 1

ClaimResponse.payment.amount

Min Cardinality changed from 0 to 1

ClaimResponse.fundsReserve

Renamed from reserved to fundsReserve
Type changed from Coding to CodeableConcept

ClaimResponse.formCode

Added Element

ClaimResponse.form

Type changed from CodeableConcept to Attachment

ClaimResponse.processNote.type

Type changed from CodeableConcept to code
Change value set from http://hl7.org/fhir/ValueSet/note-type to http://hl7.org/fhir/ValueSet/note-type|4.0.1

ClaimResponse.processNote.text

Min Cardinality changed from 0 to 1

ClaimResponse.processNote.language

Change binding strength from extensible to preferred

ClaimResponse.error.itemSequence

Renamed from sequenceLinkId to itemSequence

ClaimResponse.error.detailSequence

Renamed from detailSequenceLinkId to detailSequence

ClaimResponse.error.subDetailSequence

Renamed from subdetailSequenceLinkId to subDetailSequence

ClaimResponse.requestOrganization

deleted

ClaimResponse.addItem.revenue

deleted

ClaimResponse.addItem.category

deleted

ClaimResponse.addItem.fee

deleted

ClaimResponse.addItem.detail.revenue

deleted

ClaimResponse.addItem.detail.category

deleted

ClaimResponse.addItem.detail.fee

deleted

ClaimResponse.totalCost

deleted

ClaimResponse.unallocDeductable

deleted

ClaimResponse.totalBenefit

deleted

See the Full Difference for further information

This analysis is available as XML or JSON.

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

Structure

Name	Flags	Card.	Type	Description & Constraints
ClaimResponse	TU		DomainResource	Response to a claim predetermination or preauthorization Elements defined in Ancestors: id, meta, implicitRules, language, text, contained, extension, modifierExtension
identifier		0..*	Identifier	Business Identifier for a claim response
status	?!Σ	1..1	code	active \| cancelled \| draft \| entered-in-error Financial Resource Status Codes (Required)
type	Σ	1..1	CodeableConcept	More granular claim type Claim Type Codes (Extensible)
subType		0..1	CodeableConcept	More granular claim type Example Claim SubType Codes (Example)
use	Σ	1..1	code	claim \| preauthorization \| predetermination Use (Required)
patient	Σ	1..1	Reference(Patient)	The recipient of the products and services
created	Σ	1..1	dateTime	Response creation date
insurer	Σ	1..1	Reference(Organization)	Party responsible for reimbursement
requestor		0..1	Reference(Practitioner \| PractitionerRole \| Organization)	Party responsible for the claim
request	Σ	0..1	Reference(Claim)	Id of resource triggering adjudication
outcome	Σ	1..1	code	queued \| complete \| error \| partial Claim Processing Codes (Required)
disposition		0..1	string	Disposition Message
preAuthRef		0..1	string	Preauthorization reference
preAuthPeriod		0..1	Period	Preauthorization reference effective period
payeeType		0..1	CodeableConcept	Party to be paid any benefits payable PayeeType (Example)
item		0..*	BackboneElement	Adjudication for claim line items
itemSequence		1..1	positiveInt	Claim item instance identifier
noteNumber		0..*	positiveInt	Applicable note numbers
adjudication		1..*	BackboneElement	Adjudication details
category		1..1	CodeableConcept	Type of adjudication information Adjudication Value Codes (Example)
reason		0..1	CodeableConcept	Explanation of adjudication outcome Adjudication Reason Codes (Example)
amount		0..1	Money	Monetary amount
value		0..1	decimal	Non-monetary value
detail		0..*	BackboneElement	Adjudication for claim details
detailSequence		1..1	positiveInt	Claim detail instance identifier
noteNumber		0..*	positiveInt	Applicable note numbers
adjudication		1..*	see adjudication	Detail level adjudication details
subDetail		0..*	BackboneElement	Adjudication for claim sub-details
subDetailSequence		1..1	positiveInt	Claim sub-detail instance identifier
noteNumber		0..*	positiveInt	Applicable note numbers
adjudication		0..*	see adjudication	Subdetail level adjudication details
addItem		0..*	BackboneElement	Insurer added line items
itemSequence		0..*	positiveInt	Item sequence number
detailSequence		0..*	positiveInt	Detail sequence number
subdetailSequence		0..*	positiveInt	Subdetail sequence number
provider		0..*	Reference(Practitioner \| PractitionerRole \| Organization)	Authorized providers
productOrService		1..1	CodeableConcept	Billing, service, product, or drug code USCLS Codes (Example)
modifier		0..*	CodeableConcept	Service/Product billing modifiers Modifier type Codes (Example)
programCode		0..*	CodeableConcept	Program the product or service is provided under Example Program Reason Codes (Example)
serviced[x]		0..1		Date or dates of service or product delivery
servicedDate			date
servicedPeriod			Period
location[x]		0..1		Place of service or where product was supplied Example Service Place Codes (Example)
locationCodeableConcept			CodeableConcept
locationAddress			Address
locationReference			Reference(Location)
quantity		0..1	SimpleQuantity	Count of products or services
unitPrice		0..1	Money	Fee, charge or cost per item
factor		0..1	decimal	Price scaling factor
net		0..1	Money	Total item cost
bodySite		0..1	CodeableConcept	Anatomical location Oral Site Codes (Example)
subSite		0..*	CodeableConcept	Anatomical sub-location Surface Codes (Example)
noteNumber		0..*	positiveInt	Applicable note numbers
adjudication		1..*	see adjudication	Added items adjudication
detail		0..*	BackboneElement	Insurer added line details
productOrService		1..1	CodeableConcept	Billing, service, product, or drug code USCLS Codes (Example)
modifier		0..*	CodeableConcept	Service/Product billing modifiers Modifier type Codes (Example)
quantity		0..1	SimpleQuantity	Count of products or services
unitPrice		0..1	Money	Fee, charge or cost per item
factor		0..1	decimal	Price scaling factor
net		0..1	Money	Total item cost
noteNumber		0..*	positiveInt	Applicable note numbers
adjudication		1..*	see adjudication	Added items detail adjudication
subDetail		0..*	BackboneElement	Insurer added line items
productOrService		1..1	CodeableConcept	Billing, service, product, or drug code USCLS Codes (Example)
modifier		0..*	CodeableConcept	Service/Product billing modifiers Modifier type Codes (Example)
quantity		0..1	SimpleQuantity	Count of products or services
unitPrice		0..1	Money	Fee, charge or cost per item
factor		0..1	decimal	Price scaling factor
net		0..1	Money	Total item cost
noteNumber		0..*	positiveInt	Applicable note numbers
adjudication		1..*	see adjudication	Added items detail adjudication
adjudication		0..*	see adjudication	Header-level adjudication
total	Σ	0..*	BackboneElement	Adjudication totals
category	Σ	1..1	CodeableConcept	Type of adjudication information Adjudication Value Codes (Example)
amount	Σ	1..1	Money	Financial total for the category
payment		0..1	BackboneElement	Payment Details
type		1..1	CodeableConcept	Partial or complete payment Example Payment Type Codes (Example)
adjustment		0..1	Money	Payment adjustment for non-claim issues
adjustmentReason		0..1	CodeableConcept	Explanation for the adjustment Payment Adjustment Reason Codes (Example)
date		0..1	date	Expected date of payment
amount		1..1	Money	Payable amount after adjustment
identifier		0..1	Identifier	Business identifier for the payment
fundsReserve		0..1	CodeableConcept	Funds reserved status FundsReserve (Example)
formCode		0..1	CodeableConcept	Printed form identifier Forms (Example)
form		0..1	Attachment	Printed reference or actual form
processNote		0..*	BackboneElement	Note concerning adjudication
number		0..1	positiveInt	Note instance identifier
type		0..1	code	display \| print \| printoper NoteType (Required)
text		1..1	string	Note explanatory text
language		0..1	CodeableConcept	Language of the text Common Languages (Preferred but limited to AllLanguages)
communicationRequest		0..*	Reference(CommunicationRequest)	Request for additional information
insurance		0..*	BackboneElement	Patient insurance information
sequence		1..1	positiveInt	Insurance instance identifier
focal		1..1	boolean	Coverage to be used for adjudication
coverage		1..1	Reference(Coverage)	Insurance information
businessArrangement		0..1	string	Additional provider contract number
claimResponse		0..1	Reference(ClaimResponse)	Adjudication results
error		0..*	BackboneElement	Processing errors
itemSequence		0..1	positiveInt	Item sequence number
detailSequence		0..1	positiveInt	Detail sequence number
subDetailSequence		0..1	positiveInt	Subdetail sequence number
code		1..1	CodeableConcept	Error code detailing processing issues AdjudicationError (Example)
Documentation for this format

UML Diagram (Legend)

XML Template

<ClaimResponse xmlns="http://hl7.org/fhir"> 
 <!-- from Resource: id, meta, implicitRules, and language -->
 <!-- from DomainResource: text, contained, extension, and modifierExtension -->
 <identifier><!-- 0..* Identifier Business Identifier for a claim response --></identifier>
 <status value="[code]"/><!-- 1..1 active | cancelled | draft | entered-in-error -->
 <type><!-- 1..1 CodeableConcept More granular claim type --></type>
 <subType><!-- 0..1 CodeableConcept More granular claim type --></subType>
 <use value="[code]"/><!-- 1..1 claim | preauthorization | predetermination -->
 <patient><!-- 1..1 Reference(Patient) The recipient of the products and services --></patient>
 <created value="[dateTime]"/><!-- 1..1 Response creation date -->
 <insurer><!-- 1..1 Reference(Organization) Party responsible for reimbursement --></insurer>
 <requestor><!-- 0..1 Reference(Practitioner|PractitionerRole|Organization) Party responsible for the claim --></requestor>
 <request><!-- 0..1 Reference(Claim) Id of resource triggering adjudication --></request>
 <outcome value="[code]"/><!-- 1..1 queued | complete | error | partial -->
 <disposition value="[string]"/><!-- 0..1 Disposition Message -->
 <preAuthRef value="[string]"/><!-- 0..1 Preauthorization reference -->
 <preAuthPeriod><!-- 0..1 Period Preauthorization reference effective period --></preAuthPeriod>
 <payeeType><!-- 0..1 CodeableConcept Party to be paid any benefits payable --></payeeType>
 <item>  <!-- 0..* Adjudication for claim line items -->
  <itemSequence value="[positiveInt]"/><!-- 1..1 Claim item instance identifier -->
  <noteNumber value="[positiveInt]"/><!-- 0..* Applicable note numbers -->
  <adjudication>  <!-- 1..* Adjudication details -->
   <category><!-- 1..1 CodeableConcept Type of adjudication information --></category>
   <reason><!-- 0..1 CodeableConcept Explanation of adjudication outcome --></reason>
   <amount><!-- 0..1 Money Monetary amount --></amount>
   <value value="[decimal]"/><!-- 0..1 Non-monetary value -->
  </adjudication>
  <detail>  <!-- 0..* Adjudication for claim details -->
   <detailSequence value="[positiveInt]"/><!-- 1..1 Claim detail instance identifier -->
   <noteNumber value="[positiveInt]"/><!-- 0..* Applicable note numbers -->
   <adjudication><!-- 1..* Content as for ClaimResponse.item.adjudication Detail level adjudication details --></adjudication>
   <subDetail>  <!-- 0..* Adjudication for claim sub-details -->
    <subDetailSequence value="[positiveInt]"/><!-- 1..1 Claim sub-detail instance identifier -->
    <noteNumber value="[positiveInt]"/><!-- 0..* Applicable note numbers -->
    <adjudication><!-- 0..* Content as for ClaimResponse.item.adjudication Subdetail level adjudication details --></adjudication>
   </subDetail>
  </detail>
 </item>
 <addItem>  <!-- 0..* Insurer added line items -->
  <itemSequence value="[positiveInt]"/><!-- 0..* Item sequence number -->
  <detailSequence value="[positiveInt]"/><!-- 0..* Detail sequence number -->
  <subdetailSequence value="[positiveInt]"/><!-- 0..* Subdetail sequence number -->
  <provider><!-- 0..* Reference(Practitioner|PractitionerRole|Organization) Authorized providers --></provider>
  <productOrService><!-- 1..1 CodeableConcept Billing, service, product, or drug code --></productOrService>
  <modifier><!-- 0..* CodeableConcept Service/Product billing modifiers --></modifier>
  <programCode><!-- 0..* CodeableConcept Program the product or service is provided under --></programCode>
  <serviced[x]><!-- 0..1 date|Period Date or dates of service or product delivery --></serviced[x]>
  <location[x]><!-- 0..1 CodeableConcept|Address|Reference(Location) Place of service or where product was supplied --></location[x]>
  <quantity><!-- 0..1 Quantity(SimpleQuantity) Count of products or services --></quantity>
  <unitPrice><!-- 0..1 Money Fee, charge or cost per item --></unitPrice>
  <factor value="[decimal]"/><!-- 0..1 Price scaling factor -->
  <net><!-- 0..1 Money Total item cost --></net>
  <bodySite><!-- 0..1 CodeableConcept Anatomical location --></bodySite>
  <subSite><!-- 0..* CodeableConcept Anatomical sub-location --></subSite>
  <noteNumber value="[positiveInt]"/><!-- 0..* Applicable note numbers -->
  <adjudication><!-- 1..* Content as for ClaimResponse.item.adjudication Added items adjudication --></adjudication>
  <detail>  <!-- 0..* Insurer added line details -->
   <productOrService><!-- 1..1 CodeableConcept Billing, service, product, or drug code --></productOrService>
   <modifier><!-- 0..* CodeableConcept Service/Product billing modifiers --></modifier>
   <quantity><!-- 0..1 Quantity(SimpleQuantity) Count of products or services --></quantity>
   <unitPrice><!-- 0..1 Money Fee, charge or cost per item --></unitPrice>
   <factor value="[decimal]"/><!-- 0..1 Price scaling factor -->
   <net><!-- 0..1 Money Total item cost --></net>
   <noteNumber value="[positiveInt]"/><!-- 0..* Applicable note numbers -->
   <adjudication><!-- 1..* Content as for ClaimResponse.item.adjudication Added items detail adjudication --></adjudication>
   <subDetail>  <!-- 0..* Insurer added line items -->
    <productOrService><!-- 1..1 CodeableConcept Billing, service, product, or drug code --></productOrService>
    <modifier><!-- 0..* CodeableConcept Service/Product billing modifiers --></modifier>
    <quantity><!-- 0..1 Quantity(SimpleQuantity) Count of products or services --></quantity>
    <unitPrice><!-- 0..1 Money Fee, charge or cost per item --></unitPrice>
    <factor value="[decimal]"/><!-- 0..1 Price scaling factor -->
    <net><!-- 0..1 Money Total item cost --></net>
    <noteNumber value="[positiveInt]"/><!-- 0..* Applicable note numbers -->
    <adjudication><!-- 1..* Content as for ClaimResponse.item.adjudication Added items detail adjudication --></adjudication>
   </subDetail>
  </detail>
 </addItem>
 <adjudication><!-- 0..* Content as for ClaimResponse.item.adjudication Header-level adjudication --></adjudication>
 <total>  <!-- 0..* Adjudication totals -->
  <category><!-- 1..1 CodeableConcept Type of adjudication information --></category>
  <amount><!-- 1..1 Money Financial total for the category --></amount>
 </total>
 <payment>  <!-- 0..1 Payment Details -->
  <type><!-- 1..1 CodeableConcept Partial or complete payment --></type>
  <adjustment><!-- 0..1 Money Payment adjustment for non-claim issues --></adjustment>
  <adjustmentReason><!-- 0..1 CodeableConcept Explanation for the adjustment --></adjustmentReason>
  <date value="[date]"/><!-- 0..1 Expected date of payment -->
  <amount><!-- 1..1 Money Payable amount after adjustment --></amount>
  <identifier><!-- 0..1 Identifier Business identifier for the payment --></identifier>
 </payment>
 <fundsReserve><!-- 0..1 CodeableConcept Funds reserved status --></fundsReserve>
 <formCode><!-- 0..1 CodeableConcept Printed form identifier --></formCode>
 <form><!-- 0..1 Attachment Printed reference or actual form --></form>
 <processNote>  <!-- 0..* Note concerning adjudication -->
  <number value="[positiveInt]"/><!-- 0..1 Note instance identifier -->
  <type value="[code]"/><!-- 0..1 display | print | printoper -->
  <text value="[string]"/><!-- 1..1 Note explanatory text -->
  <language><!-- 0..1 CodeableConcept Language of the text --></language>
 </processNote>
 <communicationRequest><!-- 0..* Reference(CommunicationRequest) Request for additional information --></communicationRequest>
 <insurance>  <!-- 0..* Patient insurance information -->
  <sequence value="[positiveInt]"/><!-- 1..1 Insurance instance identifier -->
  <focal value="[boolean]"/><!-- 1..1 Coverage to be used for adjudication -->
  <coverage><!-- 1..1 Reference(Coverage) Insurance information --></coverage>
  <businessArrangement value="[string]"/><!-- 0..1 Additional provider contract number -->
  <claimResponse><!-- 0..1 Reference(ClaimResponse) Adjudication results --></claimResponse>
 </insurance>
 <error>  <!-- 0..* Processing errors -->
  <itemSequence value="[positiveInt]"/><!-- 0..1 Item sequence number -->
  <detailSequence value="[positiveInt]"/><!-- 0..1 Detail sequence number -->
  <subDetailSequence value="[positiveInt]"/><!-- 0..1 Subdetail sequence number -->
  <code><!-- 1..1 CodeableConcept Error code detailing processing issues --></code>
 </error>
</ClaimResponse>

JSON Template

{
  "resourceType" : "ClaimResponse",
  // from Resource: id, meta, implicitRules, and language
  // from DomainResource: text, contained, extension, and modifierExtension
  "identifier" : [{ Identifier }], // Business Identifier for a claim response
  "status" : "<code>", // R!  active | cancelled | draft | entered-in-error
  "type" : { CodeableConcept }, // R!  More granular claim type
  "subType" : { CodeableConcept }, // More granular claim type
  "use" : "<code>", // R!  claim | preauthorization | predetermination
  "patient" : { Reference(Patient) }, // R!  The recipient of the products and services
  "created" : "<dateTime>", // R!  Response creation date
  "insurer" : { Reference(Organization) }, // R!  Party responsible for reimbursement
  "requestor" : { Reference(Practitioner|PractitionerRole|Organization) }, // Party responsible for the claim
  "request" : { Reference(Claim) }, // Id of resource triggering adjudication
  "outcome" : "<code>", // R!  queued | complete | error | partial
  "disposition" : "<string>", // Disposition Message
  "preAuthRef" : "<string>", // Preauthorization reference
  "preAuthPeriod" : { Period }, // Preauthorization reference effective period
  "payeeType" : { CodeableConcept }, // Party to be paid any benefits payable
  "item" : [{ // Adjudication for claim line items
    "itemSequence" : "<positiveInt>", // R!  Claim item instance identifier
    "noteNumber" : ["<positiveInt>"], // Applicable note numbers
    "adjudication" : [{ // R!  Adjudication details
      "category" : { CodeableConcept }, // R!  Type of adjudication information
      "reason" : { CodeableConcept }, // Explanation of adjudication outcome
      "amount" : { Money }, // Monetary amount
      "value" : <decimal> // Non-monetary value
    }],
    "detail" : [{ // Adjudication for claim details
      "detailSequence" : "<positiveInt>", // R!  Claim detail instance identifier
      "noteNumber" : ["<positiveInt>"], // Applicable note numbers
      "adjudication" : [{ Content as for ClaimResponse.item.adjudication }], // R!  Detail level adjudication details
      "subDetail" : [{ // Adjudication for claim sub-details
        "subDetailSequence" : "<positiveInt>", // R!  Claim sub-detail instance identifier
        "noteNumber" : ["<positiveInt>"], // Applicable note numbers
        "adjudication" : [{ Content as for ClaimResponse.item.adjudication }] // Subdetail level adjudication details
      }]
    }]
  }],
  "addItem" : [{ // Insurer added line items
    "itemSequence" : ["<positiveInt>"], // Item sequence number
    "detailSequence" : ["<positiveInt>"], // Detail sequence number
    "subdetailSequence" : ["<positiveInt>"], // Subdetail sequence number
    "provider" : [{ Reference(Practitioner|PractitionerRole|Organization) }], // Authorized providers
    "productOrService" : { CodeableConcept }, // R!  Billing, service, product, or drug code
    "modifier" : [{ CodeableConcept }], // Service/Product billing modifiers
    "programCode" : [{ CodeableConcept }], // Program the product or service is provided under
    // serviced[x]: Date or dates of service or product delivery. One of these 2:
    "servicedDate" : "<date>",
    "servicedPeriod" : { Period },
    // location[x]: Place of service or where product was supplied. One of these 3:
    "locationCodeableConcept" : { CodeableConcept },
    "locationAddress" : { Address },
    "locationReference" : { Reference(Location) },
    "quantity" : { Quantity(SimpleQuantity) }, // Count of products or services
    "unitPrice" : { Money }, // Fee, charge or cost per item
    "factor" : <decimal>, // Price scaling factor
    "net" : { Money }, // Total item cost
    "bodySite" : { CodeableConcept }, // Anatomical location
    "subSite" : [{ CodeableConcept }], // Anatomical sub-location
    "noteNumber" : ["<positiveInt>"], // Applicable note numbers
    "adjudication" : [{ Content as for ClaimResponse.item.adjudication }], // R!  Added items adjudication
    "detail" : [{ // Insurer added line details
      "productOrService" : { CodeableConcept }, // R!  Billing, service, product, or drug code
      "modifier" : [{ CodeableConcept }], // Service/Product billing modifiers
      "quantity" : { Quantity(SimpleQuantity) }, // Count of products or services
      "unitPrice" : { Money }, // Fee, charge or cost per item
      "factor" : <decimal>, // Price scaling factor
      "net" : { Money }, // Total item cost
      "noteNumber" : ["<positiveInt>"], // Applicable note numbers
      "adjudication" : [{ Content as for ClaimResponse.item.adjudication }], // R!  Added items detail adjudication
      "subDetail" : [{ // Insurer added line items
        "productOrService" : { CodeableConcept }, // R!  Billing, service, product, or drug code
        "modifier" : [{ CodeableConcept }], // Service/Product billing modifiers
        "quantity" : { Quantity(SimpleQuantity) }, // Count of products or services
        "unitPrice" : { Money }, // Fee, charge or cost per item
        "factor" : <decimal>, // Price scaling factor
        "net" : { Money }, // Total item cost
        "noteNumber" : ["<positiveInt>"], // Applicable note numbers
        "adjudication" : [{ Content as for ClaimResponse.item.adjudication }] // R!  Added items detail adjudication
      }]
    }]
  }],
  "adjudication" : [{ Content as for ClaimResponse.item.adjudication }], // Header-level adjudication
  "total" : [{ // Adjudication totals
    "category" : { CodeableConcept }, // R!  Type of adjudication information
    "amount" : { Money } // R!  Financial total for the category
  }],
  "payment" : { // Payment Details
    "type" : { CodeableConcept }, // R!  Partial or complete payment
    "adjustment" : { Money }, // Payment adjustment for non-claim issues
    "adjustmentReason" : { CodeableConcept }, // Explanation for the adjustment
    "date" : "<date>", // Expected date of payment
    "amount" : { Money }, // R!  Payable amount after adjustment
    "identifier" : { Identifier } // Business identifier for the payment
  },
  "fundsReserve" : { CodeableConcept }, // Funds reserved status
  "formCode" : { CodeableConcept }, // Printed form identifier
  "form" : { Attachment }, // Printed reference or actual form
  "processNote" : [{ // Note concerning adjudication
    "number" : "<positiveInt>", // Note instance identifier
    "type" : "<code>", // display | print | printoper
    "text" : "<string>", // R!  Note explanatory text
    "language" : { CodeableConcept } // Language of the text
  }],
  "communicationRequest" : [{ Reference(CommunicationRequest) }], // Request for additional information
  "insurance" : [{ // Patient insurance information
    "sequence" : "<positiveInt>", // R!  Insurance instance identifier
    "focal" : <boolean>, // R!  Coverage to be used for adjudication
    "coverage" : { Reference(Coverage) }, // R!  Insurance information
    "businessArrangement" : "<string>", // Additional provider contract number
    "claimResponse" : { Reference(ClaimResponse) } // Adjudication results
  }],
  "error" : [{ // Processing errors
    "itemSequence" : "<positiveInt>", // Item sequence number
    "detailSequence" : "<positiveInt>", // Detail sequence number
    "subDetailSequence" : "<positiveInt>", // Subdetail sequence number
    "code" : { CodeableConcept } // R!  Error code detailing processing issues
  }]
}

Turtle Template

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


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

  # from Resource: .id, .meta, .implicitRules, and .language
  # from DomainResource: .text, .contained, .extension, and .modifierExtension
  fhir:ClaimResponse.identifier [ Identifier ], ... ; # 0..* Business Identifier for a claim response
  fhir:ClaimResponse.status [ code ]; # 1..1 active | cancelled | draft | entered-in-error
  fhir:ClaimResponse.type [ CodeableConcept ]; # 1..1 More granular claim type
  fhir:ClaimResponse.subType [ CodeableConcept ]; # 0..1 More granular claim type
  fhir:ClaimResponse.use [ code ]; # 1..1 claim | preauthorization | predetermination
  fhir:ClaimResponse.patient [ Reference(Patient) ]; # 1..1 The recipient of the products and services
  fhir:ClaimResponse.created [ dateTime ]; # 1..1 Response creation date
  fhir:ClaimResponse.insurer [ Reference(Organization) ]; # 1..1 Party responsible for reimbursement
  fhir:ClaimResponse.requestor [ Reference(Practitioner|PractitionerRole|Organization) ]; # 0..1 Party responsible for the claim
  fhir:ClaimResponse.request [ Reference(Claim) ]; # 0..1 Id of resource triggering adjudication
  fhir:ClaimResponse.outcome [ code ]; # 1..1 queued | complete | error | partial
  fhir:ClaimResponse.disposition [ string ]; # 0..1 Disposition Message
  fhir:ClaimResponse.preAuthRef [ string ]; # 0..1 Preauthorization reference
  fhir:ClaimResponse.preAuthPeriod [ Period ]; # 0..1 Preauthorization reference effective period
  fhir:ClaimResponse.payeeType [ CodeableConcept ]; # 0..1 Party to be paid any benefits payable
  fhir:ClaimResponse.item [ # 0..* Adjudication for claim line items
    fhir:ClaimResponse.item.itemSequence [ positiveInt ]; # 1..1 Claim item instance identifier
    fhir:ClaimResponse.item.noteNumber [ positiveInt ], ... ; # 0..* Applicable note numbers
    fhir:ClaimResponse.item.adjudication [ # 1..* Adjudication details
      fhir:ClaimResponse.item.adjudication.category [ CodeableConcept ]; # 1..1 Type of adjudication information
      fhir:ClaimResponse.item.adjudication.reason [ CodeableConcept ]; # 0..1 Explanation of adjudication outcome
      fhir:ClaimResponse.item.adjudication.amount [ Money ]; # 0..1 Monetary amount
      fhir:ClaimResponse.item.adjudication.value [ decimal ]; # 0..1 Non-monetary value
    ], ...;
    fhir:ClaimResponse.item.detail [ # 0..* Adjudication for claim details
      fhir:ClaimResponse.item.detail.detailSequence [ positiveInt ]; # 1..1 Claim detail instance identifier
      fhir:ClaimResponse.item.detail.noteNumber [ positiveInt ], ... ; # 0..* Applicable note numbers
      fhir:ClaimResponse.item.detail.adjudication [ See ClaimResponse.item.adjudication ], ... ; # 1..* Detail level adjudication details
      fhir:ClaimResponse.item.detail.subDetail [ # 0..* Adjudication for claim sub-details
        fhir:ClaimResponse.item.detail.subDetail.subDetailSequence [ positiveInt ]; # 1..1 Claim sub-detail instance identifier
        fhir:ClaimResponse.item.detail.subDetail.noteNumber [ positiveInt ], ... ; # 0..* Applicable note numbers
        fhir:ClaimResponse.item.detail.subDetail.adjudication [ See ClaimResponse.item.adjudication ], ... ; # 0..* Subdetail level adjudication details
      ], ...;
    ], ...;
  ], ...;
  fhir:ClaimResponse.addItem [ # 0..* Insurer added line items
    fhir:ClaimResponse.addItem.itemSequence [ positiveInt ], ... ; # 0..* Item sequence number
    fhir:ClaimResponse.addItem.detailSequence [ positiveInt ], ... ; # 0..* Detail sequence number
    fhir:ClaimResponse.addItem.subdetailSequence [ positiveInt ], ... ; # 0..* Subdetail sequence number
    fhir:ClaimResponse.addItem.provider [ Reference(Practitioner|PractitionerRole|Organization) ], ... ; # 0..* Authorized providers
    fhir:ClaimResponse.addItem.productOrService [ CodeableConcept ]; # 1..1 Billing, service, product, or drug code
    fhir:ClaimResponse.addItem.modifier [ CodeableConcept ], ... ; # 0..* Service/Product billing modifiers
    fhir:ClaimResponse.addItem.programCode [ CodeableConcept ], ... ; # 0..* Program the product or service is provided under
    # ClaimResponse.addItem.serviced[x] : 0..1 Date or dates of service or product delivery. One of these 2
      fhir:ClaimResponse.addItem.servicedDate [ date ]
      fhir:ClaimResponse.addItem.servicedPeriod [ Period ]
    # ClaimResponse.addItem.location[x] : 0..1 Place of service or where product was supplied. One of these 3
      fhir:ClaimResponse.addItem.locationCodeableConcept [ CodeableConcept ]
      fhir:ClaimResponse.addItem.locationAddress [ Address ]
      fhir:ClaimResponse.addItem.locationReference [ Reference(Location) ]
    fhir:ClaimResponse.addItem.quantity [ Quantity(SimpleQuantity) ]; # 0..1 Count of products or services
    fhir:ClaimResponse.addItem.unitPrice [ Money ]; # 0..1 Fee, charge or cost per item
    fhir:ClaimResponse.addItem.factor [ decimal ]; # 0..1 Price scaling factor
    fhir:ClaimResponse.addItem.net [ Money ]; # 0..1 Total item cost
    fhir:ClaimResponse.addItem.bodySite [ CodeableConcept ]; # 0..1 Anatomical location
    fhir:ClaimResponse.addItem.subSite [ CodeableConcept ], ... ; # 0..* Anatomical sub-location
    fhir:ClaimResponse.addItem.noteNumber [ positiveInt ], ... ; # 0..* Applicable note numbers
    fhir:ClaimResponse.addItem.adjudication [ See ClaimResponse.item.adjudication ], ... ; # 1..* Added items adjudication
    fhir:ClaimResponse.addItem.detail [ # 0..* Insurer added line details
      fhir:ClaimResponse.addItem.detail.productOrService [ CodeableConcept ]; # 1..1 Billing, service, product, or drug code
      fhir:ClaimResponse.addItem.detail.modifier [ CodeableConcept ], ... ; # 0..* Service/Product billing modifiers
      fhir:ClaimResponse.addItem.detail.quantity [ Quantity(SimpleQuantity) ]; # 0..1 Count of products or services
      fhir:ClaimResponse.addItem.detail.unitPrice [ Money ]; # 0..1 Fee, charge or cost per item
      fhir:ClaimResponse.addItem.detail.factor [ decimal ]; # 0..1 Price scaling factor
      fhir:ClaimResponse.addItem.detail.net [ Money ]; # 0..1 Total item cost
      fhir:ClaimResponse.addItem.detail.noteNumber [ positiveInt ], ... ; # 0..* Applicable note numbers
      fhir:ClaimResponse.addItem.detail.adjudication [ See ClaimResponse.item.adjudication ], ... ; # 1..* Added items detail adjudication
      fhir:ClaimResponse.addItem.detail.subDetail [ # 0..* Insurer added line items
        fhir:ClaimResponse.addItem.detail.subDetail.productOrService [ CodeableConcept ]; # 1..1 Billing, service, product, or drug code
        fhir:ClaimResponse.addItem.detail.subDetail.modifier [ CodeableConcept ], ... ; # 0..* Service/Product billing modifiers
        fhir:ClaimResponse.addItem.detail.subDetail.quantity [ Quantity(SimpleQuantity) ]; # 0..1 Count of products or services
        fhir:ClaimResponse.addItem.detail.subDetail.unitPrice [ Money ]; # 0..1 Fee, charge or cost per item
        fhir:ClaimResponse.addItem.detail.subDetail.factor [ decimal ]; # 0..1 Price scaling factor
        fhir:ClaimResponse.addItem.detail.subDetail.net [ Money ]; # 0..1 Total item cost
        fhir:ClaimResponse.addItem.detail.subDetail.noteNumber [ positiveInt ], ... ; # 0..* Applicable note numbers
        fhir:ClaimResponse.addItem.detail.subDetail.adjudication [ See ClaimResponse.item.adjudication ], ... ; # 1..* Added items detail adjudication
      ], ...;
    ], ...;
  ], ...;
  fhir:ClaimResponse.adjudication [ See ClaimResponse.item.adjudication ], ... ; # 0..* Header-level adjudication
  fhir:ClaimResponse.total [ # 0..* Adjudication totals
    fhir:ClaimResponse.total.category [ CodeableConcept ]; # 1..1 Type of adjudication information
    fhir:ClaimResponse.total.amount [ Money ]; # 1..1 Financial total for the category
  ], ...;
  fhir:ClaimResponse.payment [ # 0..1 Payment Details
    fhir:ClaimResponse.payment.type [ CodeableConcept ]; # 1..1 Partial or complete payment
    fhir:ClaimResponse.payment.adjustment [ Money ]; # 0..1 Payment adjustment for non-claim issues
    fhir:ClaimResponse.payment.adjustmentReason [ CodeableConcept ]; # 0..1 Explanation for the adjustment
    fhir:ClaimResponse.payment.date [ date ]; # 0..1 Expected date of payment
    fhir:ClaimResponse.payment.amount [ Money ]; # 1..1 Payable amount after adjustment
    fhir:ClaimResponse.payment.identifier [ Identifier ]; # 0..1 Business identifier for the payment
  ];
  fhir:ClaimResponse.fundsReserve [ CodeableConcept ]; # 0..1 Funds reserved status
  fhir:ClaimResponse.formCode [ CodeableConcept ]; # 0..1 Printed form identifier
  fhir:ClaimResponse.form [ Attachment ]; # 0..1 Printed reference or actual form
  fhir:ClaimResponse.processNote [ # 0..* Note concerning adjudication
    fhir:ClaimResponse.processNote.number [ positiveInt ]; # 0..1 Note instance identifier
    fhir:ClaimResponse.processNote.type [ code ]; # 0..1 display | print | printoper
    fhir:ClaimResponse.processNote.text [ string ]; # 1..1 Note explanatory text
    fhir:ClaimResponse.processNote.language [ CodeableConcept ]; # 0..1 Language of the text
  ], ...;
  fhir:ClaimResponse.communicationRequest [ Reference(CommunicationRequest) ], ... ; # 0..* Request for additional information
  fhir:ClaimResponse.insurance [ # 0..* Patient insurance information
    fhir:ClaimResponse.insurance.sequence [ positiveInt ]; # 1..1 Insurance instance identifier
    fhir:ClaimResponse.insurance.focal [ boolean ]; # 1..1 Coverage to be used for adjudication
    fhir:ClaimResponse.insurance.coverage [ Reference(Coverage) ]; # 1..1 Insurance information
    fhir:ClaimResponse.insurance.businessArrangement [ string ]; # 0..1 Additional provider contract number
    fhir:ClaimResponse.insurance.claimResponse [ Reference(ClaimResponse) ]; # 0..1 Adjudication results
  ], ...;
  fhir:ClaimResponse.error [ # 0..* Processing errors
    fhir:ClaimResponse.error.itemSequence [ positiveInt ]; # 0..1 Item sequence number
    fhir:ClaimResponse.error.detailSequence [ positiveInt ]; # 0..1 Detail sequence number
    fhir:ClaimResponse.error.subDetailSequence [ positiveInt ]; # 0..1 Subdetail sequence number
    fhir:ClaimResponse.error.code [ CodeableConcept ]; # 1..1 Error code detailing processing issues
  ], ...;
]

Changes since Release 3

ClaimResponse

ClaimResponse.status

Min Cardinality changed from 0 to 1
Change value set from http://hl7.org/fhir/ValueSet/fm-status to http://hl7.org/fhir/ValueSet/fm-status|4.0.1

ClaimResponse.type

Added Mandatory Element

ClaimResponse.subType

Added Element

ClaimResponse.use

Added Mandatory Element

ClaimResponse.patient

Min Cardinality changed from 0 to 1

ClaimResponse.created

Min Cardinality changed from 0 to 1

ClaimResponse.insurer

Min Cardinality changed from 0 to 1

ClaimResponse.requestor

Renamed from requestProvider to requestor
Type Reference: Added Target Types PractitionerRole, Organization

ClaimResponse.outcome

Min Cardinality changed from 0 to 1
Type changed from CodeableConcept to code
Add Binding http://hl7.org/fhir/ValueSet/remittance-outcome|4.0.1 (required)

ClaimResponse.preAuthRef

Moved from ClaimResponse.insurance to ClaimResponse
Max Cardinality changed from * to 1

ClaimResponse.preAuthPeriod

Added Element

ClaimResponse.item.itemSequence

Renamed from sequenceLinkId to itemSequence

ClaimResponse.item.adjudication

Min Cardinality changed from 0 to 1

ClaimResponse.item.detail.detailSequence

Renamed from sequenceLinkId to detailSequence

ClaimResponse.item.detail.adjudication

Min Cardinality changed from 0 to 1

ClaimResponse.item.detail.subDetail.subDetailSequence

Renamed from sequenceLinkId to subDetailSequence

ClaimResponse.addItem.itemSequence

Renamed from sequenceLinkId to itemSequence

ClaimResponse.addItem.detailSequence

Added Element

ClaimResponse.addItem.subdetailSequence

Added Element

ClaimResponse.addItem.provider

Added Element

ClaimResponse.addItem.productOrService

Renamed from service to productOrService
Min Cardinality changed from 0 to 1

ClaimResponse.addItem.programCode

Added Element

ClaimResponse.addItem.serviced[x]

Added Element

ClaimResponse.addItem.location[x]

Added Element

ClaimResponse.addItem.quantity

Added Element

ClaimResponse.addItem.unitPrice

Added Element

ClaimResponse.addItem.factor

Added Element

ClaimResponse.addItem.net

Added Element

ClaimResponse.addItem.bodySite

Added Element

ClaimResponse.addItem.subSite

Added Element

ClaimResponse.addItem.adjudication

Min Cardinality changed from 0 to 1

ClaimResponse.addItem.detail.productOrService

Renamed from service to productOrService
Min Cardinality changed from 0 to 1

ClaimResponse.addItem.detail.quantity

Added Element

ClaimResponse.addItem.detail.unitPrice

Added Element

ClaimResponse.addItem.detail.factor

Added Element

ClaimResponse.addItem.detail.net

Added Element

ClaimResponse.addItem.detail.adjudication

Min Cardinality changed from 0 to 1

ClaimResponse.addItem.detail.subDetail

Added Element

ClaimResponse.addItem.detail.subDetail.productOrService

Added Mandatory Element

ClaimResponse.addItem.detail.subDetail.modifier

Added Element

ClaimResponse.addItem.detail.subDetail.quantity

Added Element

ClaimResponse.addItem.detail.subDetail.unitPrice

Added Element

ClaimResponse.addItem.detail.subDetail.factor

Added Element

ClaimResponse.addItem.detail.subDetail.net

Added Element

ClaimResponse.addItem.detail.subDetail.noteNumber

Added Element

ClaimResponse.addItem.detail.subDetail.adjudication

Added Mandatory Element

ClaimResponse.adjudication

Added Element

ClaimResponse.total

Added Element

ClaimResponse.total.category

Added Mandatory Element

ClaimResponse.total.amount

Added Mandatory Element

ClaimResponse.payment.type

Min Cardinality changed from 0 to 1

ClaimResponse.payment.amount

Min Cardinality changed from 0 to 1

ClaimResponse.fundsReserve

Renamed from reserved to fundsReserve
Type changed from Coding to CodeableConcept

ClaimResponse.formCode

Added Element

ClaimResponse.form

Type changed from CodeableConcept to Attachment

ClaimResponse.processNote.type

Type changed from CodeableConcept to code
Change value set from http://hl7.org/fhir/ValueSet/note-type to http://hl7.org/fhir/ValueSet/note-type|4.0.1

ClaimResponse.processNote.text

Min Cardinality changed from 0 to 1

ClaimResponse.processNote.language

Change binding strength from extensible to preferred

ClaimResponse.error.itemSequence

Renamed from sequenceLinkId to itemSequence

ClaimResponse.error.detailSequence

Renamed from detailSequenceLinkId to detailSequence

ClaimResponse.error.subDetailSequence

Renamed from subdetailSequenceLinkId to subDetailSequence

ClaimResponse.requestOrganization

deleted

ClaimResponse.addItem.revenue

deleted

ClaimResponse.addItem.category

deleted

ClaimResponse.addItem.fee

deleted

ClaimResponse.addItem.detail.revenue

deleted

ClaimResponse.addItem.detail.category

deleted

ClaimResponse.addItem.detail.fee

deleted

ClaimResponse.totalCost

deleted

ClaimResponse.unallocDeductable

deleted

ClaimResponse.totalBenefit

deleted

See the Full Difference for further information

This analysis is available as XML or JSON.

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

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

13.7.3.1 Terminology Bindings

Path	Definition	Type	Reference
ClaimResponse.status	A code specifying the state of the resource instance.	Required	FinancialResourceStatusCodes
ClaimResponse.type	The type or discipline-style of the claim.	Extensible	ClaimTypeCodes
ClaimResponse.subType	A more granular claim typecode.	Example	ExampleClaimSubTypeCodes
ClaimResponse.use	Claim, preauthorization, predetermination.	Required	Use
ClaimResponse.outcome	The result of the claim processing.	Required	ClaimProcessingCodes
ClaimResponse.payeeType	A code for the party to be reimbursed.	Example	Claim Payee Type Codes
ClaimResponse.item.adjudication.category ClaimResponse.total.category	The adjudication codes.	Example	AdjudicationValueCodes
ClaimResponse.item.adjudication.reason	The adjudication reason codes.	Example	AdjudicationReasonCodes
ClaimResponse.addItem.productOrService ClaimResponse.addItem.detail.productOrService ClaimResponse.addItem.detail.subDetail.productOrService	Allowable service and product codes.	Example	USCLSCodes
ClaimResponse.addItem.modifier ClaimResponse.addItem.detail.modifier ClaimResponse.addItem.detail.subDetail.modifier	Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.	Example	ModifierTypeCodes
ClaimResponse.addItem.programCode	Program specific reason codes.	Example	ExampleProgramReasonCodes
ClaimResponse.addItem.location[x]	Place of service: pharmacy, school, prison, etc.	Example	ExampleServicePlaceCodes
ClaimResponse.addItem.bodySite	The code for the teeth, quadrant, sextant and arch.	Example	OralSiteCodes
ClaimResponse.addItem.subSite	The code for the tooth surface and surface combinations.	Example	SurfaceCodes
ClaimResponse.payment.type	The type (partial, complete) of the payment.	Example	ExamplePaymentTypeCodes
ClaimResponse.payment.adjustmentReason	Payment Adjustment reason codes.	Example	PaymentAdjustmentReasonCodes
ClaimResponse.fundsReserve	For whom funds are to be reserved: (Patient, Provider, None).	Example	Funds Reservation Codes
ClaimResponse.formCode	The forms codes.	Example	Form Codes
ClaimResponse.processNote.type	The presentation types of notes.	Required	NoteType
ClaimResponse.processNote.language	A human language.	Preferred, but limited to AllLanguages	CommonLanguages
ClaimResponse.error.code	The adjudication error codes.	Example	Adjudication Error Codes

Path

Definition

Type

Reference

ClaimResponse.status

A code specifying the state of the resource instance.

Required

FinancialResourceStatusCodes

ClaimResponse.type

The type or discipline-style of the claim.

Extensible

ClaimTypeCodes

ClaimResponse.subType

A more granular claim typecode.

Example

ExampleClaimSubTypeCodes

ClaimResponse.use

Claim, preauthorization, predetermination.

Required

Use

ClaimResponse.outcome

The result of the claim processing.

Required

ClaimProcessingCodes

ClaimResponse.payeeType

A code for the party to be reimbursed.

Example

Claim Payee Type Codes

ClaimResponse.item.adjudication.category
ClaimResponse.total.category

The adjudication codes.

Example

AdjudicationValueCodes

ClaimResponse.item.adjudication.reason

The adjudication reason codes.

Example

AdjudicationReasonCodes

ClaimResponse.addItem.productOrService
ClaimResponse.addItem.detail.productOrService
ClaimResponse.addItem.detail.subDetail.productOrService

Allowable service and product codes.

Example

USCLSCodes

ClaimResponse.addItem.modifier
ClaimResponse.addItem.detail.modifier
ClaimResponse.addItem.detail.subDetail.modifier

Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.

Example

ModifierTypeCodes

ClaimResponse.addItem.programCode

Program specific reason codes.

Example

ExampleProgramReasonCodes

ClaimResponse.addItem.location[x]

Place of service: pharmacy, school, prison, etc.

Example

ExampleServicePlaceCodes

ClaimResponse.addItem.bodySite

The code for the teeth, quadrant, sextant and arch.

Example

OralSiteCodes

ClaimResponse.addItem.subSite

The code for the tooth surface and surface combinations.

Example

SurfaceCodes

ClaimResponse.payment.type

The type (partial, complete) of the payment.

Example

ExamplePaymentTypeCodes

ClaimResponse.payment.adjustmentReason

Payment Adjustment reason codes.

Example

PaymentAdjustmentReasonCodes

ClaimResponse.fundsReserve

For whom funds are to be reserved: (Patient, Provider, None).

Example

Funds Reservation Codes

ClaimResponse.formCode

The forms codes.

Example

Form Codes

ClaimResponse.processNote.type

The presentation types of notes.

Required

NoteType

ClaimResponse.processNote.language

A human language.

Preferred, but limited to AllLanguages

CommonLanguages

ClaimResponse.error.code

The adjudication error codes.

Example

Adjudication Error Codes

13.7.4 Search Parameters

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

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