Release 5

This page is part of the FHIR Specification (v5.0.0: R5 - STU). This is the current published version in it's permanent home (it will always be available at this URL). 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 icon Work GroupMaturity Level: 2 Trial UseSecurity Category: Patient Compartments: Patient, Practitioner

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

13.7.1 Scope and Usage

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

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

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

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

13.7.1.1 Additional Information

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

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

13.7.2 Boundaries and Relationships

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

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

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

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

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

13.7.3 References to this Resource

13.7.4 Resource Content

Structure

NameFlagsCard.TypeDescription & Constraintsdoco
.. ClaimResponse TUDomainResourceResponse to a claim predetermination or preauthorization

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

... traceNumber 0..*IdentifierNumber for tracking

... status ?!Σ1..1codeactive | cancelled | draft | entered-in-error
Binding: Financial Resource Status Codes (Required)
... type Σ1..1CodeableConceptMore granular claim type
Binding: Claim Type Codes (Extensible)
... subType 0..1CodeableConceptMore granular claim type
Binding: Example Claim SubType Codes (Example)
... use Σ1..1codeclaim | preauthorization | predetermination
Binding: Use (Required)
... patient Σ1..1Reference(Patient)The recipient of the products and services
... created Σ1..1dateTimeResponse creation date
... insurer Σ0..1Reference(Organization)Party responsible for reimbursement
... requestor 0..1Reference(Practitioner | PractitionerRole | Organization)Party responsible for the claim
... request Σ0..1Reference(Claim)Id of resource triggering adjudication
... outcome Σ1..1codequeued | complete | error | partial
Binding: Claim Processing Codes (Required)
... decision Σ0..1CodeableConceptResult of the adjudication
Binding: Claim Adjudication Decision Codes (Example)
... disposition 0..1stringDisposition Message
... preAuthRef 0..1stringPreauthorization reference
... preAuthPeriod 0..1PeriodPreauthorization reference effective period
... event 0..*BackboneElementEvent information

.... type 1..1CodeableConceptSpecific event
Binding: Dates Type Codes (Example)
.... when[x] 1..1Occurance date or period
..... whenDateTimedateTime
..... whenPeriodPeriod
... payeeType 0..1CodeableConceptParty to be paid any benefits payable
Binding: Claim Payee Type Codes (Example)
... encounter 0..*Reference(Encounter)Encounters associated with the listed treatments

... diagnosisRelatedGroup 0..1CodeableConceptPackage billing code
Binding: Example Diagnosis Related Group Codes (Example)
... item 0..*BackboneElementAdjudication for claim line items

.... itemSequence 1..1positiveIntClaim item instance identifier
.... traceNumber 0..*IdentifierNumber for tracking

.... noteNumber 0..*positiveIntApplicable note numbers

.... reviewOutcome 0..1BackboneElementAdjudication results
..... decision 0..1CodeableConceptResult of the adjudication
Binding: Claim Adjudication Decision Codes (Example)
..... reason 0..*CodeableConceptReason for result of the adjudication
Binding: Claim Adjudication Decision Reason Codes (Example)

..... preAuthRef 0..1stringPreauthorization reference
..... preAuthPeriod 0..1PeriodPreauthorization reference effective period
.... adjudication 0..*BackboneElementAdjudication details

..... category 1..1CodeableConceptType of adjudication information
Binding: Adjudication Value Codes (Example)
..... reason 0..1CodeableConceptExplanation of adjudication outcome
Binding: Adjudication Reason Codes (Example)
..... amount 0..1MoneyMonetary amount
..... quantity 0..1QuantityNon-monetary value
.... detail 0..*BackboneElementAdjudication for claim details

..... detailSequence 1..1positiveIntClaim detail instance identifier
..... traceNumber 0..*IdentifierNumber for tracking

..... noteNumber 0..*positiveIntApplicable note numbers

..... reviewOutcome 0..1see reviewOutcomeDetail level adjudication results
..... adjudication 0..*see adjudicationDetail level adjudication details

..... subDetail 0..*BackboneElementAdjudication for claim sub-details

...... subDetailSequence 1..1positiveIntClaim sub-detail instance identifier
...... traceNumber 0..*IdentifierNumber for tracking

...... noteNumber 0..*positiveIntApplicable note numbers

...... reviewOutcome 0..1see reviewOutcomeSubdetail level adjudication results
...... adjudication 0..*see adjudicationSubdetail level adjudication details

... addItem 0..*BackboneElementInsurer added line items

.... itemSequence 0..*positiveIntItem sequence number

.... detailSequence 0..*positiveIntDetail sequence number

.... subdetailSequence 0..*positiveIntSubdetail sequence number

.... traceNumber 0..*IdentifierNumber for tracking

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

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

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

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

.... serviced[x] 0..1Date or dates of service or product delivery
..... servicedDatedate
..... servicedPeriodPeriod
.... location[x] 0..1Place of service or where product was supplied
Binding: Example Service Place Codes (Example)
..... locationCodeableConceptCodeableConcept
..... locationAddressAddress
..... locationReferenceReference(Location)
.... quantity 0..1SimpleQuantityCount of products or services
.... unitPrice 0..1MoneyFee, charge or cost per item
.... factor 0..1decimalPrice scaling factor
.... tax 0..1MoneyTotal tax
.... net 0..1MoneyTotal item cost
.... bodySite 0..*BackboneElementAnatomical location

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

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

.... noteNumber 0..*positiveIntApplicable note numbers

.... reviewOutcome 0..1see reviewOutcomeAdded items adjudication results
.... adjudication 0..*see adjudicationAdded items adjudication

.... detail 0..*BackboneElementInsurer added line details

..... traceNumber 0..*IdentifierNumber for tracking

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

..... quantity 0..1SimpleQuantityCount of products or services
..... unitPrice 0..1MoneyFee, charge or cost per item
..... factor 0..1decimalPrice scaling factor
..... tax 0..1MoneyTotal tax
..... net 0..1MoneyTotal item cost
..... noteNumber 0..*positiveIntApplicable note numbers

..... reviewOutcome 0..1see reviewOutcomeAdded items detail level adjudication results
..... adjudication 0..*see adjudicationAdded items detail adjudication

..... subDetail 0..*BackboneElementInsurer added line items

...... traceNumber 0..*IdentifierNumber for tracking

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

...... quantity 0..1SimpleQuantityCount of products or services
...... unitPrice 0..1MoneyFee, charge or cost per item
...... factor 0..1decimalPrice scaling factor
...... tax 0..1MoneyTotal tax
...... net 0..1MoneyTotal item cost
...... noteNumber 0..*positiveIntApplicable note numbers

...... reviewOutcome 0..1see reviewOutcomeAdded items subdetail level adjudication results
...... adjudication 0..*see adjudicationAdded items subdetail adjudication

... adjudication 0..*see adjudicationHeader-level adjudication

... total Σ0..*BackboneElementAdjudication totals

.... category Σ1..1CodeableConceptType of adjudication information
Binding: Adjudication Value Codes (Example)
.... amount Σ1..1MoneyFinancial total for the category
... payment 0..1BackboneElementPayment Details
.... type 1..1CodeableConceptPartial or complete payment
Binding: Example Payment Type Codes (Example)
.... adjustment 0..1MoneyPayment adjustment for non-claim issues
.... adjustmentReason 0..1CodeableConceptExplanation for the adjustment
Binding: Payment Adjustment Reason Codes (Example)
.... date 0..1dateExpected date of payment
.... amount 1..1MoneyPayable amount after adjustment
.... identifier 0..1IdentifierBusiness identifier for the payment
... fundsReserve 0..1CodeableConceptFunds reserved status
Binding: Funds Reservation Codes (Example)
... formCode 0..1CodeableConceptPrinted form identifier
Binding: Form Codes (Example)
... form 0..1AttachmentPrinted reference or actual form
... processNote 0..*BackboneElementNote concerning adjudication

.... number 0..1positiveIntNote instance identifier
.... type 0..1CodeableConceptNote purpose
Binding: NoteType (Extensible)
.... text 1..1stringNote explanatory text
.... language 0..1CodeableConceptLanguage of the text
Binding: All Languages (Required)
Additional BindingsPurpose
Common LanguagesStarter Set

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

... insurance 0..*BackboneElementPatient insurance information

.... sequence 1..1positiveIntInsurance instance identifier
.... focal 1..1booleanCoverage to be used for adjudication
.... coverage 1..1Reference(Coverage)Insurance information
.... businessArrangement 0..1stringAdditional provider contract number
.... claimResponse 0..1Reference(ClaimResponse)Adjudication results
... error 0..*BackboneElementProcessing errors

.... itemSequence 0..1positiveIntItem sequence number
.... detailSequence 0..1positiveIntDetail sequence number
.... subDetailSequence 0..1positiveIntSubdetail sequence number
.... code Σ1..1CodeableConceptError code detailing processing issues
Binding: Adjudication Error Codes (Example)
.... expression Σ0..*stringFHIRPath of element(s) related to issue


doco Documentation for this format icon

See the Extensions for this resource

UML Diagram (Legend)

ClaimResponse (DomainResource)⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนidentifier : Identifier [0..*]⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนtraceNumber : Identifier [0..*]⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนstatus : code [1..1] « ⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนFinancialResourceStatusCodes! »⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนtype : CodeableConcept [1..1] « ⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนClaimTypeCodes+ »⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนsubType : CodeableConcept [0..1] « ⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนExampleClaimSubTypeCodes?? »⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนuse : code [1..1] « ⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนUse! »⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนpatient : Reference [1..1] « Patient »⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนcreated : dateTime [1..1]⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนinsurer : Reference [0..1] « Organization »⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนrequestor : Reference [0..1] « Practitioner|PractitionerRole| Organization »⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนrequest : Reference [0..1] « Claim »⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนoutcome : code [1..1] « ⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนClaimProcessingCodes! »⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนdecision : CodeableConcept [0..1] « ⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนClaimAdjudicationDecisionsCod...?? »⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนdisposition : string [0..1]⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนpreAuthRef : string [0..1]⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนpreAuthPeriod : Period [0..1]⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนpayeeType : CodeableConcept [0..1] « ⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนClaimPayeeTypeCodes?? »⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนencounter : Reference [0..*] « Encounter »⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนdiagnosisRelatedGroup : CodeableConcept [0..1] « ⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อน ExampleDiagnosisRelatedGroupC...?? »⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนfundsReserve : CodeableConcept [0..1] « ⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนFundsReservationCodes?? »⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนformCode : CodeableConcept [0..1] « ⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนFormCodes?? »⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนform : Attachment [0..1]⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนcommunicationRequest : Reference [0..*] « CommunicationRequest »Event⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนtype : CodeableConcept [1..1] « ⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนDatesTypeCodes?? »⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนwhen[x] : DataType [1..1] « dateTime|Period »Item⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนitemSequence : positiveInt [1..1]⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนtraceNumber : Identifier [0..*]⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนnoteNumber : positiveInt [0..*]ReviewOutcome⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนdecision : CodeableConcept [0..1] « ⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนClaimAdjudicationDecisionsCod...?? »⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนreason : CodeableConcept [0..*] « ⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนClaimAdjudicationDecisionReas...?? »⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนpreAuthRef : string [0..1]⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนpreAuthPeriod : Period [0..1]Adjudication⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนcategory : CodeableConcept [1..1] « ⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนAdjudicationValueCodes?? »⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนreason : CodeableConcept [0..1] « ⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนAdjudicationReasonCodes?? »⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนamount : Money [0..1]⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนquantity : Quantity [0..1]ItemDetail⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนdetailSequence : positiveInt [1..1]⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนtraceNumber : Identifier [0..*]⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนnoteNumber : positiveInt [0..*]SubDetail⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนsubDetailSequence : positiveInt [1..1]⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนtraceNumber : Identifier [0..*]⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนnoteNumber : positiveInt [0..*]AddedItem⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนitemSequence : positiveInt [0..*]⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนdetailSequence : positiveInt [0..*]⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนsubdetailSequence : positiveInt [0..*]⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนtraceNumber : Identifier [0..*]⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนprovider : Reference [0..*] « Practitioner|PractitionerRole| Organization »⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนrevenue : CodeableConcept [0..1] « ⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนExampleRevenueCenterCodes?? »⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนproductOrService : CodeableConcept [0..1] « ⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนUSCLSCodes?? »⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนproductOrServiceEnd : CodeableConcept [0..1] « ⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนUSCLSCodes?? »⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนrequest : Reference [0..*] « DeviceRequest|MedicationRequest| NutritionOrder|ServiceRequest|SupplyRequest|VisionPrescription »⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนmodifier : CodeableConcept [0..*] « ⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนModifierTypeCodes?? »⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนprogramCode : CodeableConcept [0..*] « ⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนExampleProgramReasonCodes?? »⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนserviced[x] : DataType [0..1] « date|Period »⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนlocation[x] : DataType [0..1] « CodeableConcept|Address|Reference( Location); ⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนExampleServicePlaceCodes?? »⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนquantity : Quantity(SimpleQuantity) [0..1]⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนunitPrice : Money [0..1]⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนfactor : decimal [0..1]⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนtax : Money [0..1]⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนnet : Money [0..1]⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนnoteNumber : positiveInt [0..*]BodySite⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนsite : CodeableReference [1..*] « BodyStructure; ⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนOralSiteCodes?? »⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนsubSite : CodeableConcept [0..*] « ⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนSurfaceCodes?? »AddedItemDetail⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนtraceNumber : Identifier [0..*]⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนrevenue : CodeableConcept [0..1] « ⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนExampleRevenueCenterCodes?? »⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนproductOrService : CodeableConcept [0..1] « ⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนUSCLSCodes?? »⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนproductOrServiceEnd : CodeableConcept [0..1] « ⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนUSCLSCodes?? »⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนmodifier : CodeableConcept [0..*] « ⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนModifierTypeCodes?? »⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนquantity : Quantity(SimpleQuantity) [0..1]⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนunitPrice : Money [0..1]⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนfactor : decimal [0..1]⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนtax : Money [0..1]⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนnet : Money [0..1]⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนnoteNumber : positiveInt [0..*]AddedItemSubDetail⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนtraceNumber : Identifier [0..*]⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนrevenue : CodeableConcept [0..1] « ⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนExampleRevenueCenterCodes?? »⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนproductOrService : CodeableConcept [0..1] « ⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนUSCLSCodes?? »⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนproductOrServiceEnd : CodeableConcept [0..1] « ⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนUSCLSCodes?? »⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนmodifier : CodeableConcept [0..*] « ⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนModifierTypeCodes?? »⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนquantity : Quantity(SimpleQuantity) [0..1]⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนunitPrice : Money [0..1]⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนfactor : decimal [0..1]⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนtax : Money [0..1]⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนnet : Money [0..1]⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนnoteNumber : positiveInt [0..*]Total⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนcategory : CodeableConcept [1..1] « ⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนAdjudicationValueCodes?? »⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนamount : Money [1..1]Payment⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนtype : CodeableConcept [1..1] « ⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนExamplePaymentTypeCodes?? »⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนadjustment : Money [0..1]⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนadjustmentReason : CodeableConcept [0..1] « ⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อน PaymentAdjustmentReasonCodes?? »⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนdate : date [0..1]⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนamount : Money [1..1]⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนidentifier : Identifier [0..1]Note⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนnumber : positiveInt [0..1]⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนtype : CodeableConcept [0..1] « ⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนNoteType+ »⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนtext : string [1..1]⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนlanguage : CodeableConcept [0..1] « ⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนAllLanguages! »Insurance⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนsequence : positiveInt [1..1]⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนfocal : boolean [1..1]⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนcoverage : Reference [1..1] « Coverage »⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนbusinessArrangement : string [0..1]⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนclaimResponse : Reference [0..1] « ClaimResponse »Error⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนitemSequence : positiveInt [0..1]⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนdetailSequence : positiveInt [0..1]⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนsubDetailSequence : positiveInt [0..1]⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนcode : CodeableConcept [1..1] « ⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนAdjudicationErrorCodes?? »⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนexpression : string [0..*]⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนevent[0..*]⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนreviewOutcome[0..1]⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนadjudication[0..*]⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนreviewOutcome[0..1]⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนadjudication[0..*]⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนreviewOutcome[0..1]⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนadjudication[0..*]⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนsubDetail[0..*]⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนdetail[0..*]⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนitem[0..*]⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนbodySite[0..*]⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนreviewOutcome[0..1]⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนadjudication[0..*]⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนreviewOutcome[0..1]⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนadjudication[0..*]⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนreviewOutcome[0..1]⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนadjudication[0..*]⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนsubDetail[0..*]⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนdetail[0..*]⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนaddItem[0..*]⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนadjudication[0..*]⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนtotal[0..*]⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนpayment[0..1]⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนprocessNote[0..*]⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนinsurance[0..*]⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนerror[0..*]

XML Template

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

JSON Template

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

Turtle Template

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


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

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

Changes from both R4 and R4B

ClaimResponse
ClaimResponse.traceNumber
  • Added Element
ClaimResponse.insurer
  • Min Cardinality changed from 1 to 0
ClaimResponse.outcome
ClaimResponse.decision
  • Added Element
ClaimResponse.event
  • Added Element
ClaimResponse.event.type
  • Added Mandatory Element
ClaimResponse.event.when[x]
  • Added Mandatory Element
ClaimResponse.encounter
  • Added Element
ClaimResponse.diagnosisRelatedGroup
  • Added Element
ClaimResponse.item.traceNumber
  • Added Element
ClaimResponse.item.reviewOutcome
  • Added Element
ClaimResponse.item.reviewOutcome.decision
  • Added Element
ClaimResponse.item.reviewOutcome.reason
  • Added Element
ClaimResponse.item.reviewOutcome.preAuthRef
  • Added Element
ClaimResponse.item.reviewOutcome.preAuthPeriod
  • Added Element
ClaimResponse.item.adjudication
  • Min Cardinality changed from 1 to 0
ClaimResponse.item.adjudication.quantity
  • Added Element
ClaimResponse.item.detail.traceNumber
  • Added Element
ClaimResponse.item.detail.reviewOutcome
  • Added Element
ClaimResponse.item.detail.adjudication
  • Min Cardinality changed from 1 to 0
ClaimResponse.item.detail.subDetail.traceNumber
  • Added Element
ClaimResponse.item.detail.subDetail.reviewOutcome
  • Added Element
ClaimResponse.addItem.traceNumber
  • Added Element
ClaimResponse.addItem.revenue
  • Added Element
ClaimResponse.addItem.productOrService
  • Min Cardinality changed from 1 to 0
ClaimResponse.addItem.productOrServiceEnd
  • Added Element
ClaimResponse.addItem.request
  • Added Element
ClaimResponse.addItem.tax
  • Added Element
ClaimResponse.addItem.bodySite
  • Max Cardinality changed from 1 to *
  • Type changed from CodeableConcept to BackboneElement
ClaimResponse.addItem.bodySite.site
  • Added Mandatory Element
ClaimResponse.addItem.bodySite.subSite
  • Added Element
ClaimResponse.addItem.reviewOutcome
  • Added Element
ClaimResponse.addItem.adjudication
  • Min Cardinality changed from 1 to 0
ClaimResponse.addItem.detail.traceNumber
  • Added Element
ClaimResponse.addItem.detail.revenue
  • Added Element
ClaimResponse.addItem.detail.productOrService
  • Min Cardinality changed from 1 to 0
ClaimResponse.addItem.detail.productOrServiceEnd
  • Added Element
ClaimResponse.addItem.detail.tax
  • Added Element
ClaimResponse.addItem.detail.reviewOutcome
  • Added Element
ClaimResponse.addItem.detail.adjudication
  • Min Cardinality changed from 1 to 0
ClaimResponse.addItem.detail.subDetail.traceNumber
  • Added Element
ClaimResponse.addItem.detail.subDetail.revenue
  • Added Element
ClaimResponse.addItem.detail.subDetail.productOrService
  • Min Cardinality changed from 1 to 0
ClaimResponse.addItem.detail.subDetail.productOrServiceEnd
  • Added Element
ClaimResponse.addItem.detail.subDetail.tax
  • Added Element
ClaimResponse.addItem.detail.subDetail.reviewOutcome
  • Added Element
ClaimResponse.addItem.detail.subDetail.adjudication
  • Min Cardinality changed from 1 to 0
ClaimResponse.processNote.type
  • Type changed from code to CodeableConcept
  • Change binding strength from required to extensible
ClaimResponse.processNote.language
ClaimResponse.error.expression
  • Added Element
ClaimResponse.item.adjudication.value
  • Deleted
ClaimResponse.addItem.subSite
  • Deleted

See the Full Difference for further information

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

See R4 <--> R5 Conversion Maps (status = See Conversions Summary.)

Structure

NameFlagsCard.TypeDescription & Constraintsdoco
.. ClaimResponse TUDomainResourceResponse to a claim predetermination or preauthorization

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

... traceNumber 0..*IdentifierNumber for tracking

... status ?!Σ1..1codeactive | cancelled | draft | entered-in-error
Binding: Financial Resource Status Codes (Required)
... type Σ1..1CodeableConceptMore granular claim type
Binding: Claim Type Codes (Extensible)
... subType 0..1CodeableConceptMore granular claim type
Binding: Example Claim SubType Codes (Example)
... use Σ1..1codeclaim | preauthorization | predetermination
Binding: Use (Required)
... patient Σ1..1Reference(Patient)The recipient of the products and services
... created Σ1..1dateTimeResponse creation date
... insurer Σ0..1Reference(Organization)Party responsible for reimbursement
... requestor 0..1Reference(Practitioner | PractitionerRole | Organization)Party responsible for the claim
... request Σ0..1Reference(Claim)Id of resource triggering adjudication
... outcome Σ1..1codequeued | complete | error | partial
Binding: Claim Processing Codes (Required)
... decision Σ0..1CodeableConceptResult of the adjudication
Binding: Claim Adjudication Decision Codes (Example)
... disposition 0..1stringDisposition Message
... preAuthRef 0..1stringPreauthorization reference
... preAuthPeriod 0..1PeriodPreauthorization reference effective period
... event 0..*BackboneElementEvent information

.... type 1..1CodeableConceptSpecific event
Binding: Dates Type Codes (Example)
.... when[x] 1..1Occurance date or period
..... whenDateTimedateTime
..... whenPeriodPeriod
... payeeType 0..1CodeableConceptParty to be paid any benefits payable
Binding: Claim Payee Type Codes (Example)
... encounter 0..*Reference(Encounter)Encounters associated with the listed treatments

... diagnosisRelatedGroup 0..1CodeableConceptPackage billing code
Binding: Example Diagnosis Related Group Codes (Example)
... item 0..*BackboneElementAdjudication for claim line items

.... itemSequence 1..1positiveIntClaim item instance identifier
.... traceNumber 0..*IdentifierNumber for tracking

.... noteNumber 0..*positiveIntApplicable note numbers

.... reviewOutcome 0..1BackboneElementAdjudication results
..... decision 0..1CodeableConceptResult of the adjudication
Binding: Claim Adjudication Decision Codes (Example)
..... reason 0..*CodeableConceptReason for result of the adjudication
Binding: Claim Adjudication Decision Reason Codes (Example)

..... preAuthRef 0..1stringPreauthorization reference
..... preAuthPeriod 0..1PeriodPreauthorization reference effective period
.... adjudication 0..*BackboneElementAdjudication details

..... category 1..1CodeableConceptType of adjudication information
Binding: Adjudication Value Codes (Example)
..... reason 0..1CodeableConceptExplanation of adjudication outcome
Binding: Adjudication Reason Codes (Example)
..... amount 0..1MoneyMonetary amount
..... quantity 0..1QuantityNon-monetary value
.... detail 0..*BackboneElementAdjudication for claim details

..... detailSequence 1..1positiveIntClaim detail instance identifier
..... traceNumber 0..*IdentifierNumber for tracking

..... noteNumber 0..*positiveIntApplicable note numbers

..... reviewOutcome 0..1see reviewOutcomeDetail level adjudication results
..... adjudication 0..*see adjudicationDetail level adjudication details

..... subDetail 0..*BackboneElementAdjudication for claim sub-details

...... subDetailSequence 1..1positiveIntClaim sub-detail instance identifier
...... traceNumber 0..*IdentifierNumber for tracking

...... noteNumber 0..*positiveIntApplicable note numbers

...... reviewOutcome 0..1see reviewOutcomeSubdetail level adjudication results
...... adjudication 0..*see adjudicationSubdetail level adjudication details

... addItem 0..*BackboneElementInsurer added line items

.... itemSequence 0..*positiveIntItem sequence number

.... detailSequence 0..*positiveIntDetail sequence number

.... subdetailSequence 0..*positiveIntSubdetail sequence number

.... traceNumber 0..*IdentifierNumber for tracking

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

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

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

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

.... serviced[x] 0..1Date or dates of service or product delivery
..... servicedDatedate
..... servicedPeriodPeriod
.... location[x] 0..1Place of service or where product was supplied
Binding: Example Service Place Codes (Example)
..... locationCodeableConceptCodeableConcept
..... locationAddressAddress
..... locationReferenceReference(Location)
.... quantity 0..1SimpleQuantityCount of products or services
.... unitPrice 0..1MoneyFee, charge or cost per item
.... factor 0..1decimalPrice scaling factor
.... tax 0..1MoneyTotal tax
.... net 0..1MoneyTotal item cost
.... bodySite 0..*BackboneElementAnatomical location

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

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

.... noteNumber 0..*positiveIntApplicable note numbers

.... reviewOutcome 0..1see reviewOutcomeAdded items adjudication results
.... adjudication 0..*see adjudicationAdded items adjudication

.... detail 0..*BackboneElementInsurer added line details

..... traceNumber 0..*IdentifierNumber for tracking

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

..... quantity 0..1SimpleQuantityCount of products or services
..... unitPrice 0..1MoneyFee, charge or cost per item
..... factor 0..1decimalPrice scaling factor
..... tax 0..1MoneyTotal tax
..... net 0..1MoneyTotal item cost
..... noteNumber 0..*positiveIntApplicable note numbers

..... reviewOutcome 0..1see reviewOutcomeAdded items detail level adjudication results
..... adjudication 0..*see adjudicationAdded items detail adjudication

..... subDetail 0..*BackboneElementInsurer added line items

...... traceNumber 0..*IdentifierNumber for tracking

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

...... quantity 0..1SimpleQuantityCount of products or services
...... unitPrice 0..1MoneyFee, charge or cost per item
...... factor 0..1decimalPrice scaling factor
...... tax 0..1MoneyTotal tax
...... net 0..1MoneyTotal item cost
...... noteNumber 0..*positiveIntApplicable note numbers

...... reviewOutcome 0..1see reviewOutcomeAdded items subdetail level adjudication results
...... adjudication 0..*see adjudicationAdded items subdetail adjudication

... adjudication 0..*see adjudicationHeader-level adjudication

... total Σ0..*BackboneElementAdjudication totals

.... category Σ1..1CodeableConceptType of adjudication information
Binding: Adjudication Value Codes (Example)
.... amount Σ1..1MoneyFinancial total for the category
... payment 0..1BackboneElementPayment Details
.... type 1..1CodeableConceptPartial or complete payment
Binding: Example Payment Type Codes (Example)
.... adjustment 0..1MoneyPayment adjustment for non-claim issues
.... adjustmentReason 0..1CodeableConceptExplanation for the adjustment
Binding: Payment Adjustment Reason Codes (Example)
.... date 0..1dateExpected date of payment
.... amount 1..1MoneyPayable amount after adjustment
.... identifier 0..1IdentifierBusiness identifier for the payment
... fundsReserve 0..1CodeableConceptFunds reserved status
Binding: Funds Reservation Codes (Example)
... formCode 0..1CodeableConceptPrinted form identifier
Binding: Form Codes (Example)
... form 0..1AttachmentPrinted reference or actual form
... processNote 0..*BackboneElementNote concerning adjudication

.... number 0..1positiveIntNote instance identifier
.... type 0..1CodeableConceptNote purpose
Binding: NoteType (Extensible)
.... text 1..1stringNote explanatory text
.... language 0..1CodeableConceptLanguage of the text
Binding: All Languages (Required)
Additional BindingsPurpose
Common LanguagesStarter Set

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

... insurance 0..*BackboneElementPatient insurance information

.... sequence 1..1positiveIntInsurance instance identifier
.... focal 1..1booleanCoverage to be used for adjudication
.... coverage 1..1Reference(Coverage)Insurance information
.... businessArrangement 0..1stringAdditional provider contract number
.... claimResponse 0..1Reference(ClaimResponse)Adjudication results
... error 0..*BackboneElementProcessing errors

.... itemSequence 0..1positiveIntItem sequence number
.... detailSequence 0..1positiveIntDetail sequence number
.... subDetailSequence 0..1positiveIntSubdetail sequence number
.... code Σ1..1CodeableConceptError code detailing processing issues
Binding: Adjudication Error Codes (Example)
.... expression Σ0..*stringFHIRPath of element(s) related to issue


doco Documentation for this format icon

See the Extensions for this resource

UML Diagram (Legend)

ClaimResponse (DomainResource)⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนidentifier : Identifier [0..*]⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนtraceNumber : Identifier [0..*]⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนstatus : code [1..1] « ⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนFinancialResourceStatusCodes! »⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนtype : CodeableConcept [1..1] « ⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนClaimTypeCodes+ »⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนsubType : CodeableConcept [0..1] « ⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนExampleClaimSubTypeCodes?? »⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนuse : code [1..1] « ⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนUse! »⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนpatient : Reference [1..1] « Patient »⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนcreated : dateTime [1..1]⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนinsurer : Reference [0..1] « Organization »⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนrequestor : Reference [0..1] « Practitioner|PractitionerRole| Organization »⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนrequest : Reference [0..1] « Claim »⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนoutcome : code [1..1] « ⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนClaimProcessingCodes! »⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนdecision : CodeableConcept [0..1] « ⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนClaimAdjudicationDecisionsCod...?? »⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนdisposition : string [0..1]⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนpreAuthRef : string [0..1]⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนpreAuthPeriod : Period [0..1]⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนpayeeType : CodeableConcept [0..1] « ⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนClaimPayeeTypeCodes?? »⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนencounter : Reference [0..*] « Encounter »⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนdiagnosisRelatedGroup : CodeableConcept [0..1] « ⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อน ExampleDiagnosisRelatedGroupC...?? »⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนfundsReserve : CodeableConcept [0..1] « ⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนFundsReservationCodes?? »⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนformCode : CodeableConcept [0..1] « ⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนFormCodes?? »⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนform : Attachment [0..1]⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนcommunicationRequest : Reference [0..*] « CommunicationRequest »Event⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนtype : CodeableConcept [1..1] « ⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนDatesTypeCodes?? »⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนwhen[x] : DataType [1..1] « dateTime|Period »Item⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนitemSequence : positiveInt [1..1]⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนtraceNumber : Identifier [0..*]⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนnoteNumber : positiveInt [0..*]ReviewOutcome⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนdecision : CodeableConcept [0..1] « ⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนClaimAdjudicationDecisionsCod...?? »⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนreason : CodeableConcept [0..*] « ⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนClaimAdjudicationDecisionReas...?? »⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนpreAuthRef : string [0..1]⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนpreAuthPeriod : Period [0..1]Adjudication⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนcategory : CodeableConcept [1..1] « ⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนAdjudicationValueCodes?? »⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนreason : CodeableConcept [0..1] « ⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนAdjudicationReasonCodes?? »⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนamount : Money [0..1]⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนquantity : Quantity [0..1]ItemDetail⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนdetailSequence : positiveInt [1..1]⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนtraceNumber : Identifier [0..*]⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนnoteNumber : positiveInt [0..*]SubDetail⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนsubDetailSequence : positiveInt [1..1]⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนtraceNumber : Identifier [0..*]⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนnoteNumber : positiveInt [0..*]AddedItem⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนitemSequence : positiveInt [0..*]⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนdetailSequence : positiveInt [0..*]⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนsubdetailSequence : positiveInt [0..*]⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนtraceNumber : Identifier [0..*]⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนprovider : Reference [0..*] « Practitioner|PractitionerRole| Organization »⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนrevenue : CodeableConcept [0..1] « ⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนExampleRevenueCenterCodes?? »⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนproductOrService : CodeableConcept [0..1] « ⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนUSCLSCodes?? »⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนproductOrServiceEnd : CodeableConcept [0..1] « ⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนUSCLSCodes?? »⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนrequest : Reference [0..*] « DeviceRequest|MedicationRequest| NutritionOrder|ServiceRequest|SupplyRequest|VisionPrescription »⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนmodifier : CodeableConcept [0..*] « ⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนModifierTypeCodes?? »⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนprogramCode : CodeableConcept [0..*] « ⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนExampleProgramReasonCodes?? »⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนserviced[x] : DataType [0..1] « date|Period »⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนlocation[x] : DataType [0..1] « CodeableConcept|Address|Reference( Location); ⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนExampleServicePlaceCodes?? »⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนquantity : Quantity(SimpleQuantity) [0..1]⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนunitPrice : Money [0..1]⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนfactor : decimal [0..1]⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนtax : Money [0..1]⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนnet : Money [0..1]⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนnoteNumber : positiveInt [0..*]BodySite⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนsite : CodeableReference [1..*] « BodyStructure; ⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนOralSiteCodes?? »⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนsubSite : CodeableConcept [0..*] « ⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนSurfaceCodes?? »AddedItemDetail⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนtraceNumber : Identifier [0..*]⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนrevenue : CodeableConcept [0..1] « ⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนExampleRevenueCenterCodes?? »⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนproductOrService : CodeableConcept [0..1] « ⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนUSCLSCodes?? »⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนproductOrServiceEnd : CodeableConcept [0..1] « ⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนUSCLSCodes?? »⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนmodifier : CodeableConcept [0..*] « ⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนModifierTypeCodes?? »⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนquantity : Quantity(SimpleQuantity) [0..1]⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนunitPrice : Money [0..1]⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนfactor : decimal [0..1]⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนtax : Money [0..1]⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนnet : Money [0..1]⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนnoteNumber : positiveInt [0..*]AddedItemSubDetail⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนtraceNumber : Identifier [0..*]⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนrevenue : CodeableConcept [0..1] « ⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนExampleRevenueCenterCodes?? »⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนproductOrService : CodeableConcept [0..1] « ⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนUSCLSCodes?? »⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนproductOrServiceEnd : CodeableConcept [0..1] « ⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนUSCLSCodes?? »⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนmodifier : CodeableConcept [0..*] « ⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนModifierTypeCodes?? »⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนquantity : Quantity(SimpleQuantity) [0..1]⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนunitPrice : Money [0..1]⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนfactor : decimal [0..1]⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนtax : Money [0..1]⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนnet : Money [0..1]⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนnoteNumber : positiveInt [0..*]Total⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนcategory : CodeableConcept [1..1] « ⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนAdjudicationValueCodes?? »⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนamount : Money [1..1]Payment⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนtype : CodeableConcept [1..1] « ⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนExamplePaymentTypeCodes?? »⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนadjustment : Money [0..1]⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนadjustmentReason : CodeableConcept [0..1] « ⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อน PaymentAdjustmentReasonCodes?? »⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนdate : date [0..1]⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนamount : Money [1..1]⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนidentifier : Identifier [0..1]Note⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนnumber : positiveInt [0..1]⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนtype : CodeableConcept [0..1] « ⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนNoteType+ »⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนtext : string [1..1]⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนlanguage : CodeableConcept [0..1] « ⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนAllLanguages! »Insurance⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนsequence : positiveInt [1..1]⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนfocal : boolean [1..1]⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนcoverage : Reference [1..1] « Coverage »⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนbusinessArrangement : string [0..1]⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนclaimResponse : Reference [0..1] « ClaimResponse »Error⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนitemSequence : positiveInt [0..1]⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนdetailSequence : positiveInt [0..1]⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนsubDetailSequence : positiveInt [0..1]⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนcode : CodeableConcept [1..1] « ⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนAdjudicationErrorCodes?? »⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนexpression : string [0..*]⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนevent[0..*]⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนreviewOutcome[0..1]⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนadjudication[0..*]⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนreviewOutcome[0..1]⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนadjudication[0..*]⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนreviewOutcome[0..1]⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนadjudication[0..*]⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนsubDetail[0..*]⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนdetail[0..*]⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนitem[0..*]⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนbodySite[0..*]⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนreviewOutcome[0..1]⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนadjudication[0..*]⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนreviewOutcome[0..1]⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนadjudication[0..*]⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนreviewOutcome[0..1]⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนadjudication[0..*]⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนsubDetail[0..*]⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนdetail[0..*]⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนaddItem[0..*]⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนadjudication[0..*]⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนtotal[0..*]⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนpayment[0..1]⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนprocessNote[0..*]⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนinsurance[0..*]⭐ Must Read: fhir/R/claimresponse.html - ประเด็นร้อนerror[0..*]

XML Template

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

JSON Template

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

Turtle Template

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


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

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

Changes from both R4 and R4B

ClaimResponse
ClaimResponse.traceNumber
  • Added Element
ClaimResponse.insurer
  • Min Cardinality changed from 1 to 0
ClaimResponse.outcome
ClaimResponse.decision
  • Added Element
ClaimResponse.event
  • Added Element
ClaimResponse.event.type
  • Added Mandatory Element
ClaimResponse.event.when[x]
  • Added Mandatory Element
ClaimResponse.encounter
  • Added Element
ClaimResponse.diagnosisRelatedGroup
  • Added Element
ClaimResponse.item.traceNumber
  • Added Element
ClaimResponse.item.reviewOutcome
  • Added Element
ClaimResponse.item.reviewOutcome.decision
  • Added Element
ClaimResponse.item.reviewOutcome.reason
  • Added Element
ClaimResponse.item.reviewOutcome.preAuthRef
  • Added Element
ClaimResponse.item.reviewOutcome.preAuthPeriod
  • Added Element
ClaimResponse.item.adjudication
  • Min Cardinality changed from 1 to 0
ClaimResponse.item.adjudication.quantity
  • Added Element
ClaimResponse.item.detail.traceNumber
  • Added Element
ClaimResponse.item.detail.reviewOutcome
  • Added Element
ClaimResponse.item.detail.adjudication
  • Min Cardinality changed from 1 to 0
ClaimResponse.item.detail.subDetail.traceNumber
  • Added Element
ClaimResponse.item.detail.subDetail.reviewOutcome
  • Added Element
ClaimResponse.addItem.traceNumber
  • Added Element
ClaimResponse.addItem.revenue
  • Added Element
ClaimResponse.addItem.productOrService
  • Min Cardinality changed from 1 to 0
ClaimResponse.addItem.productOrServiceEnd
  • Added Element
ClaimResponse.addItem.request
  • Added Element
ClaimResponse.addItem.tax
  • Added Element
ClaimResponse.addItem.bodySite
  • Max Cardinality changed from 1 to *
  • Type changed from CodeableConcept to BackboneElement
ClaimResponse.addItem.bodySite.site
  • Added Mandatory Element
ClaimResponse.addItem.bodySite.subSite
  • Added Element
ClaimResponse.addItem.reviewOutcome
  • Added Element
ClaimResponse.addItem.adjudication
  • Min Cardinality changed from 1 to 0
ClaimResponse.addItem.detail.traceNumber
  • Added Element
ClaimResponse.addItem.detail.revenue
  • Added Element
ClaimResponse.addItem.detail.productOrService
  • Min Cardinality changed from 1 to 0
ClaimResponse.addItem.detail.productOrServiceEnd
  • Added Element
ClaimResponse.addItem.detail.tax
  • Added Element
ClaimResponse.addItem.detail.reviewOutcome
  • Added Element
ClaimResponse.addItem.detail.adjudication
  • Min Cardinality changed from 1 to 0
ClaimResponse.addItem.detail.subDetail.traceNumber
  • Added Element
ClaimResponse.addItem.detail.subDetail.revenue
  • Added Element
ClaimResponse.addItem.detail.subDetail.productOrService
  • Min Cardinality changed from 1 to 0
ClaimResponse.addItem.detail.subDetail.productOrServiceEnd
  • Added Element
ClaimResponse.addItem.detail.subDetail.tax
  • Added Element
ClaimResponse.addItem.detail.subDetail.reviewOutcome
  • Added Element
ClaimResponse.addItem.detail.subDetail.adjudication
  • Min Cardinality changed from 1 to 0
ClaimResponse.processNote.type
  • Type changed from code to CodeableConcept
  • Change binding strength from required to extensible
ClaimResponse.processNote.language
ClaimResponse.error.expression
  • Added Element
ClaimResponse.item.adjudication.value
  • Deleted
ClaimResponse.addItem.subSite
  • Deleted

See the Full Difference for further information

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

See R4 <--> R5 Conversion Maps (status = See Conversions Summary.)

 

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

13.7.4.1 Terminology Bindings

PathValueSetTypeDocumentation
ClaimResponse.status FinancialResourceStatusCodes Required

This value set includes Status codes.
ClaimResponse.type ClaimTypeCodes Extensible

This value set includes Claim Type codes.
ClaimResponse.subType ExampleClaimSubTypeCodes Example

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

The purpose of the Claim: predetermination, preauthorization, claim.
ClaimResponse.outcome ClaimProcessingCodes (a valid code from Claim Processing Outcome Codes)Required

This value set includes Claim Processing Outcome codes.
ClaimResponse.decision ClaimAdjudicationDecisionsCodes (a valid code from Claim Adjudication Decision Codes)Example

This value set includes Claim Adjudication Decision codes.
ClaimResponse.event.type DatesTypeCodes (a valid code from Dates Event Type Codes)Example

This value set includes sample Dates Type codes.
ClaimResponse.payeeType ClaimPayeeTypeCodes Example

This value set includes sample Payee Type codes.
ClaimResponse.diagnosisRelatedGroup ExampleDiagnosisRelatedGroupCodes Example

This value set includes example Diagnosis Related Group codes.
ClaimResponse.item.reviewOutcome.decision ClaimAdjudicationDecisionsCodes (a valid code from Claim Adjudication Decision Codes)Example

This value set includes Claim Adjudication Decision codes.
ClaimResponse.item.reviewOutcome.reason ClaimAdjudicationDecisionReasonCodes Example

This value set includes example Claim Adjudication Decision Reason codes.
ClaimResponse.item.adjudication.category AdjudicationValueCodes Example

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

This value set includes smattering of Adjudication Reason codes.
ClaimResponse.addItem.revenue ExampleRevenueCenterCodes Example

This value set includes sample Revenue Center codes.
ClaimResponse.addItem.productOrService USCLSCodes Example

This value set includes a smattering of USCLS codes.
ClaimResponse.addItem.productOrServiceEnd USCLSCodes Example

This value set includes a smattering of USCLS codes.
ClaimResponse.addItem.modifier ModifierTypeCodes Example

This value set includes sample Modifier type codes.
ClaimResponse.addItem.programCode ExampleProgramReasonCodes Example

This value set includes sample Program Reason Span codes.
ClaimResponse.addItem.location[x] ExampleServicePlaceCodes Example

This value set includes a smattering of Service Place codes.
ClaimResponse.addItem.bodySite.site OralSiteCodes Example

This value set includes a smattering of FDI oral site codes.
ClaimResponse.addItem.bodySite.subSite SurfaceCodes Example

This value set includes a smattering of FDI tooth surface codes.
ClaimResponse.addItem.detail.revenue ExampleRevenueCenterCodes Example

This value set includes sample Revenue Center codes.
ClaimResponse.addItem.detail.productOrService USCLSCodes Example

This value set includes a smattering of USCLS codes.
ClaimResponse.addItem.detail.productOrServiceEnd USCLSCodes Example

This value set includes a smattering of USCLS codes.
ClaimResponse.addItem.detail.modifier ModifierTypeCodes Example

This value set includes sample Modifier type codes.
ClaimResponse.addItem.detail.subDetail.revenue ExampleRevenueCenterCodes Example

This value set includes sample Revenue Center codes.
ClaimResponse.addItem.detail.subDetail.productOrService USCLSCodes Example

This value set includes a smattering of USCLS codes.
ClaimResponse.addItem.detail.subDetail.productOrServiceEnd USCLSCodes Example

This value set includes a smattering of USCLS codes.
ClaimResponse.addItem.detail.subDetail.modifier ModifierTypeCodes Example

This value set includes sample Modifier type codes.
ClaimResponse.total.category AdjudicationValueCodes Example

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

This value set includes example Payment Type codes.
ClaimResponse.payment.adjustmentReason PaymentAdjustmentReasonCodes Example

This value set includes smattering of Payment Adjustment Reason codes.
ClaimResponse.fundsReserve FundsReservationCodes Example

This value set includes sample funds reservation type codes.
ClaimResponse.formCode FormCodes Example

This value set includes a sample set of Forms codes.
ClaimResponse.processNote.type NoteType Extensible

The presentation types of notes.
ClaimResponse.processNote.language AllLanguages (a valid code from Tags for the Identification of Languages icon)Required

This value set includes all possible codes from BCP-47 (see http://tools.ietf.org/html/bcp47)
  Common Languages starter
ClaimResponse.error.code AdjudicationErrorCodes Example

This value set includes a smattering of adjudication codes.

13.7.5 Additional Information

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

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

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

13.7.6 Search Parameters

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

NameTypeDescriptionExpressionIn Common
createddateThe creation dateClaimResponse.created
dispositionstringThe contents of the disposition messageClaimResponse.disposition
identifiertokenThe identity of the ClaimResponseClaimResponse.identifier65 Resources
insurerreferenceThe organization which generated this resourceClaimResponse.insurer
(Organization)
outcometokenThe processing outcomeClaimResponse.outcome
patientreferenceThe subject of careClaimResponse.patient
(Patient)		66 Resources
payment-datedateThe expected payment dateClaimResponse.payment.date
requestreferenceThe claim referenceClaimResponse.request
(Claim)
requestorreferenceThe Provider of the claimClaimResponse.requestor
(Practitioner, Organization, PractitionerRole)
statustokenThe status of the ClaimResponseClaimResponse.status
usetokenThe type of claimClaimResponse.use