http://hl7.org/fhir/StructureDefinition/ClaimResponse|5.0.0

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

Structure JSON Dependencies FHIRSchema Other Versions Dependant (0)Elements Summary

Name	Flags	Card	Type	Description & Constraints
ClaimResponse		0..*		Response to a claim predetermination or preauthorization
identifier		0..*	Identifier	Business Identifier for a claim response
traceNumber		0..*	Identifier	Number for tracking
status *	?!Σ	1..1	code	active \| cancelled \| draft \| entered-in-error ClaimResponseStatus (required)
type *	Σ	1..1	CodeableConcept	More granular claim type ClaimType (extensible)
subType		0..1	CodeableConcept	More granular claim type ClaimSubType (example)
use *	Σ	1..1	code	claim \| preauthorization \| predetermination Use (required)
patient *	Σ	1..1	Reference	The recipient of the products and services
created *	Σ	1..1	dateTime	Response creation date
insurer	Σ	0..1	Reference	Party responsible for reimbursement
requestor		0..1	Reference	Party responsible for the claim
request	Σ	0..1	Reference	Id of resource triggering adjudication
outcome *	Σ	1..1	code	queued \| complete \| error \| partial RemittanceOutcome (required)
decision	Σ	0..1	CodeableConcept	Result of the adjudication AdjudicationDecision (example)
disposition		0..1	string	Disposition Message
preAuthRef		0..1	string	Preauthorization reference
preAuthPeriod		0..1	Period	Preauthorization reference effective period
event		0..*	BackboneElement	Event information
type *		1..1	CodeableConcept	Specific event DatesType (example)
when[x] *		1..1		Occurance date or period
whenDateTime *		1..1	dateTime
whenPeriod *		1..1	Period
payeeType		0..1	CodeableConcept	Party to be paid any benefits payable PayeeType (example)
encounter		0..*	Reference	Encounters associated with the listed treatments
diagnosisRelatedGroup		0..1	CodeableConcept	Package billing code DiagnosisRelatedGroup (example)
item		0..*	BackboneElement	Adjudication for claim line items
itemSequence *		1..1	positiveInt	Claim item instance identifier
traceNumber		0..*	Identifier	Number for tracking
noteNumber		0..*	positiveInt	Applicable note numbers
reviewOutcome		0..1	BackboneElement	Adjudication results
decision		0..1	CodeableConcept	Result of the adjudication AdjudicationDecision (example)
reason		0..*	CodeableConcept	Reason for result of the adjudication AdjudicationDecisionReason (example)
preAuthRef		0..1	string	Preauthorization reference
preAuthPeriod		0..1	Period	Preauthorization reference effective period
adjudication		0..*	BackboneElement	Adjudication details
category *		1..1	CodeableConcept	Type of adjudication information Adjudication (example)
reason		0..1	CodeableConcept	Explanation of adjudication outcome AdjudicationReason (example)
amount		0..1	Money	Monetary amount
quantity		0..1	Quantity	Non-monetary value
detail		0..*	BackboneElement	Adjudication for claim details
detailSequence *		1..1	positiveInt	Claim detail instance identifier
traceNumber		0..*	Identifier	Number for tracking
noteNumber		0..*	positiveInt	Applicable note numbers
reviewOutcome		0..1		Detail level adjudication results
adjudication		0..*		Detail level adjudication details
subDetail		0..*	BackboneElement	Adjudication for claim sub-details
subDetailSequence *		1..1	positiveInt	Claim sub-detail instance identifier
traceNumber		0..*	Identifier	Number for tracking
noteNumber		0..*	positiveInt	Applicable note numbers
reviewOutcome		0..1		Subdetail level adjudication results
adjudication		0..*		Subdetail level adjudication details
addItem		0..*	BackboneElement	Insurer added line items
itemSequence		0..*	positiveInt	Item sequence number
detailSequence		0..*	positiveInt	Detail sequence number
subdetailSequence		0..*	positiveInt	Subdetail sequence number
traceNumber		0..*	Identifier	Number for tracking
provider		0..*	Reference	Authorized providers
revenue		0..1	CodeableConcept	Revenue or cost center code RevenueCenter (example)
productOrService		0..1	CodeableConcept	Billing, service, product, or drug code ServiceProduct (example)
productOrServiceEnd		0..1	CodeableConcept	End of a range of codes ServiceProduct (example)
request		0..*	Reference	Request or Referral for Service
modifier		0..*	CodeableConcept	Service/Product billing modifiers Modifiers (example)
programCode		0..*	CodeableConcept	Program the product or service is provided under ProgramCode (example)
serviced[x]		0..1		Date or dates of service or product delivery
servicedDate		0..1	date
servicedPeriod		0..1	Period
location[x]		0..1		Place of service or where product was supplied ServicePlace (example)
locationCodeableConcept		0..1	CodeableConcept	ServicePlace (example)
locationAddress		0..1	Address	ServicePlace (example)
locationReference		0..1	Reference	ServicePlace (example)
quantity		0..1	Quantity	Count of products or services
unitPrice		0..1	Money	Fee, charge or cost per item
factor		0..1	decimal	Price scaling factor
tax		0..1	Money	Total tax
net		0..1	Money	Total item cost
bodySite		0..*	BackboneElement	Anatomical location
site *		1..*	CodeableReference	Location OralSites (example)
subSite		0..*	CodeableConcept	Sub-location Surface (example)
noteNumber		0..*	positiveInt	Applicable note numbers
reviewOutcome		0..1		Added items adjudication results
adjudication		0..*		Added items adjudication
detail		0..*	BackboneElement	Insurer added line details
traceNumber		0..*	Identifier	Number for tracking
revenue		0..1	CodeableConcept	Revenue or cost center code RevenueCenter (example)
productOrService		0..1	CodeableConcept	Billing, service, product, or drug code ServiceProduct (example)
productOrServiceEnd		0..1	CodeableConcept	End of a range of codes ServiceProduct (example)
modifier		0..*	CodeableConcept	Service/Product billing modifiers Modifiers (example)
quantity		0..1	Quantity	Count of products or services
unitPrice		0..1	Money	Fee, charge or cost per item
factor		0..1	decimal	Price scaling factor
tax		0..1	Money	Total tax
net		0..1	Money	Total item cost
noteNumber		0..*	positiveInt	Applicable note numbers
reviewOutcome		0..1		Added items detail level adjudication results
adjudication		0..*		Added items detail adjudication
subDetail		0..*	BackboneElement	Insurer added line items
traceNumber		0..*	Identifier	Number for tracking
revenue		0..1	CodeableConcept	Revenue or cost center code RevenueCenter (example)
productOrService		0..1	CodeableConcept	Billing, service, product, or drug code ServiceProduct (example)
productOrServiceEnd		0..1	CodeableConcept	End of a range of codes ServiceProduct (example)
modifier		0..*	CodeableConcept	Service/Product billing modifiers Modifiers (example)
quantity		0..1	Quantity	Count of products or services
unitPrice		0..1	Money	Fee, charge or cost per item
factor		0..1	decimal	Price scaling factor
tax		0..1	Money	Total tax
net		0..1	Money	Total item cost
noteNumber		0..*	positiveInt	Applicable note numbers
reviewOutcome		0..1		Added items subdetail level adjudication results
adjudication		0..*		Added items subdetail adjudication
adjudication		0..*		Header-level adjudication
total	Σ	0..*	BackboneElement	Adjudication totals
category *	Σ	1..1	CodeableConcept	Type of adjudication information Adjudication (example)
amount *	Σ	1..1	Money	Financial total for the category
payment		0..1	BackboneElement	Payment Details
type *		1..1	CodeableConcept	Partial or complete payment PaymentType (example)
adjustment		0..1	Money	Payment adjustment for non-claim issues
adjustmentReason		0..1	CodeableConcept	Explanation for the adjustment PaymentAdjustmentReason (example)
date		0..1	date	Expected date of payment
amount *		1..1	Money	Payable amount after adjustment
identifier		0..1	Identifier	Business identifier for the payment
fundsReserve		0..1	CodeableConcept	Funds reserved status FundsReserve (example)
formCode		0..1	CodeableConcept	Printed form identifier Forms (example)
form		0..1	Attachment	Printed reference or actual form
processNote		0..*	BackboneElement	Note concerning adjudication
number		0..1	positiveInt	Note instance identifier
type		0..1	CodeableConcept	Note purpose NoteType (extensible)
text *		1..1	string	Note explanatory text
language		0..1	CodeableConcept	Language of the text Language (required)
communicationRequest		0..*	Reference	Request for additional information
insurance		0..*	BackboneElement	Patient insurance information
sequence *		1..1	positiveInt	Insurance instance identifier
focal *		1..1	boolean	Coverage to be used for adjudication
coverage *		1..1	Reference	Insurance information
businessArrangement		0..1	string	Additional provider contract number
claimResponse		0..1	Reference	Adjudication results
error		0..*	BackboneElement	Processing errors
itemSequence		0..1	positiveInt	Item sequence number
detailSequence		0..1	positiveInt	Detail sequence number
subDetailSequence		0..1	positiveInt	Subdetail sequence number
code *	Σ	1..1	CodeableConcept	Error code detailing processing issues AdjudicationError (example)
expression	Σ	0..*	string	FHIRPath of element(s) related to issue