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
description: This resource provides the adjudication details from the processing of a Claim resource.
derivation: specialization
name: ClaimResponse
type: ClaimResponse
elements:
  patient: {isModifier: false, short: The recipient of the products and services, mustSupport: false, isSummary: true, index: 6}
  requestor: {isModifier: false, short: Party responsible for the claim, mustSupport: false, isSummary: false, index: 9}
  payeeType:
    isModifier: false
    short: Party to be paid any benefits payable
    mustSupport: false
    binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/payeetype'}
    isSummary: false
    index: 20
  insurance:
    isModifier: false
    short: Patient insurance information
    mustSupport: false
    array: true
    isSummary: false
    index: 124
    elements:
      sequence: {isModifier: false, short: Insurance instance identifier, mustSupport: false, isSummary: false, index: 125}
      focal: {isModifier: false, short: Coverage to be used for adjudication, mustSupport: false, isSummary: false, index: 126}
      coverage: {isModifier: false, short: Insurance information, mustSupport: false, isSummary: false, index: 127}
      businessArrangement: {isModifier: false, short: Additional provider contract number, mustSupport: false, isSummary: false, index: 128}
      claimResponse: {isModifier: false, short: Adjudication results, mustSupport: false, isSummary: false, index: 129}
    required: [coverage, focal, sequence]
  request: {isModifier: false, short: Id of resource triggering adjudication, mustSupport: false, isSummary: true, index: 10}
  processNote:
    isModifier: false
    short: Note concerning adjudication
    mustSupport: false
    array: true
    isSummary: false
    index: 118
    elements:
      number: {isModifier: false, short: Note instance identifier, mustSupport: false, isSummary: false, index: 119}
      type:
        isModifier: false
        short: Note purpose
        mustSupport: false
        binding: {strength: extensible, valueSet: 'http://hl7.org/fhir/ValueSet/note-type'}
        isSummary: false
        index: 120
      text: {isModifier: false, short: Note explanatory text, mustSupport: false, isSummary: false, index: 121}
      language:
        isModifier: false
        short: Language of the text
        mustSupport: false
        binding: {strength: required, valueSet: 'http://hl7.org/fhir/ValueSet/all-languages|5.0.0'}
        isSummary: false
        index: 122
    required: [text]
  preAuthRef: {isModifier: false, short: Preauthorization reference, mustSupport: false, isSummary: false, index: 14}
  adjudication:
    elementReference: ['http://hl7.org/fhir/StructureDefinition/ClaimResponse', elements, item, elements, adjudication]
    isModifier: false
    short: Header-level adjudication
    mustSupport: false
    array: true
    isSummary: false
    index: 104
  encounter: {isModifier: false, short: Encounters associated with the listed treatments, mustSupport: false, array: true, isSummary: false, index: 21}
  use:
    isModifier: false
    short: claim | preauthorization | predetermination
    mustSupport: false
    binding: {strength: required, valueSet: 'http://hl7.org/fhir/ValueSet/claim-use|5.0.0'}
    isSummary: true
    index: 5
  payment:
    isModifier: false
    short: Payment Details
    mustSupport: false
    isSummary: false
    index: 108
    elements:
      type:
        isModifier: false
        short: Partial or complete payment
        mustSupport: false
        binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/ex-paymenttype'}
        isSummary: false
        index: 109
      adjustment: {isModifier: false, short: Payment adjustment for non-claim issues, mustSupport: false, isSummary: false, index: 110}
      adjustmentReason:
        isModifier: false
        short: Explanation for the adjustment
        mustSupport: false
        binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/payment-adjustment-reason'}
        isSummary: false
        index: 111
      date: {isModifier: false, short: Expected date of payment, mustSupport: false, isSummary: false, index: 112}
      amount: {isModifier: false, short: Payable amount after adjustment, mustSupport: false, isSummary: false, index: 113}
      identifier: {isModifier: false, short: Business identifier for the payment, mustSupport: false, isSummary: false, index: 114}
    required: [type, amount]
  traceNumber: {isModifier: false, short: Number for tracking, mustSupport: false, array: true, isSummary: false, index: 1}
  item:
    isModifier: false
    short: Adjudication for claim line items
    mustSupport: false
    array: true
    isSummary: false
    index: 23
    elements:
      itemSequence: {isModifier: false, short: Claim item instance identifier, mustSupport: false, isSummary: false, index: 24}
      traceNumber: {isModifier: false, short: Number for tracking, mustSupport: false, array: true, isSummary: false, index: 25}
      noteNumber: {isModifier: false, short: Applicable note numbers, mustSupport: false, array: true, isSummary: false, index: 26}
      reviewOutcome:
        isModifier: false
        short: Adjudication results
        mustSupport: false
        isSummary: false
        index: 27
        elements:
          decision:
            isModifier: false
            short: Result of the adjudication
            mustSupport: false
            binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/claim-decision'}
            isSummary: false
            index: 28
          reason:
            isModifier: false
            short: Reason for result of the adjudication
            mustSupport: false
            array: true
            binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/claim-decision-reason'}
            isSummary: false
            index: 29
          preAuthRef: {isModifier: false, short: Preauthorization reference, mustSupport: false, isSummary: false, index: 30}
          preAuthPeriod: {isModifier: false, short: Preauthorization reference effective period, mustSupport: false, isSummary: false, index: 31}
      adjudication:
        isModifier: false
        short: Adjudication details
        mustSupport: false
        array: true
        isSummary: false
        index: 32
        elements:
          category:
            isModifier: false
            short: Type of adjudication information
            mustSupport: false
            binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/adjudication'}
            isSummary: false
            index: 33
          reason:
            isModifier: false
            short: Explanation of adjudication outcome
            mustSupport: false
            binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/adjudication-reason'}
            isSummary: false
            index: 34
          amount: {isModifier: false, short: Monetary amount, mustSupport: false, isSummary: false, index: 35}
          quantity: {isModifier: false, short: Non-monetary value, mustSupport: false, isSummary: false, index: 36}
        required: [category]
      detail:
        isModifier: false
        short: Adjudication for claim details
        mustSupport: false
        array: true
        isSummary: false
        index: 37
        elements:
          detailSequence: {isModifier: false, short: Claim detail instance identifier, mustSupport: false, isSummary: false, index: 38}
          traceNumber: {isModifier: false, short: Number for tracking, mustSupport: false, array: true, isSummary: false, index: 39}
          noteNumber: {isModifier: false, short: Applicable note numbers, mustSupport: false, array: true, isSummary: false, index: 40}
          reviewOutcome:
            elementReference: ['http://hl7.org/fhir/StructureDefinition/ClaimResponse', elements, item, elements, reviewOutcome]
            isModifier: false
            short: Detail level adjudication results
            mustSupport: false
            isSummary: false
            index: 41
          adjudication:
            elementReference: ['http://hl7.org/fhir/StructureDefinition/ClaimResponse', elements, item, elements, adjudication]
            isModifier: false
            short: Detail level adjudication details
            mustSupport: false
            array: true
            isSummary: false
            index: 42
          subDetail:
            isModifier: false
            short: Adjudication for claim sub-details
            mustSupport: false
            array: true
            isSummary: false
            index: 43
            elements:
              subDetailSequence: {isModifier: false, short: Claim sub-detail instance identifier, mustSupport: false, isSummary: false, index: 44}
              traceNumber: {isModifier: false, short: Number for tracking, mustSupport: false, array: true, isSummary: false, index: 45}
              noteNumber: {isModifier: false, short: Applicable note numbers, mustSupport: false, array: true, isSummary: false, index: 46}
              reviewOutcome:
                elementReference: ['http://hl7.org/fhir/StructureDefinition/ClaimResponse', elements, item, elements, reviewOutcome]
                isModifier: false
                short: Subdetail level adjudication results
                mustSupport: false
                isSummary: false
                index: 47
              adjudication:
                elementReference: ['http://hl7.org/fhir/StructureDefinition/ClaimResponse', elements, item, elements, adjudication]
                isModifier: false
                short: Subdetail level adjudication details
                mustSupport: false
                array: true
                isSummary: false
                index: 48
            required: [subDetailSequence]
        required: [detailSequence]
    required: [itemSequence]
  type:
    isModifier: false
    short: More granular claim type
    mustSupport: false
    binding: {strength: extensible, valueSet: 'http://hl7.org/fhir/ValueSet/claim-type'}
    isSummary: true
    index: 3
  created: {isModifier: false, short: Response creation date, mustSupport: false, isSummary: true, index: 7}
  preAuthPeriod: {isModifier: false, short: Preauthorization reference effective period, mustSupport: false, isSummary: false, index: 15}
  outcome:
    isModifier: false
    short: queued | complete | error | partial
    mustSupport: false
    binding: {strength: required, valueSet: 'http://hl7.org/fhir/ValueSet/claim-outcome|5.0.0'}
    isSummary: true
    index: 11
  disposition: {isModifier: false, short: Disposition Message, mustSupport: false, isSummary: false, index: 13}
  communicationRequest: {isModifier: false, short: Request for additional information, mustSupport: false, array: true, isSummary: false, index: 123}
  diagnosisRelatedGroup:
    isModifier: false
    short: Package billing code
    mustSupport: false
    binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/ex-diagnosisrelatedgroup'}
    isSummary: false
    index: 22
  total:
    isModifier: false
    short: Adjudication totals
    mustSupport: false
    array: true
    isSummary: true
    index: 105
    elements:
      category:
        isModifier: false
        short: Type of adjudication information
        mustSupport: false
        binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/adjudication'}
        isSummary: true
        index: 106
      amount: {isModifier: false, short: Financial total for the category, mustSupport: false, isSummary: true, index: 107}
    required: [amount, category]
  event:
    isModifier: false
    short: Event information
    mustSupport: false
    array: true
    isSummary: false
    index: 16
    elements:
      type:
        isModifier: false
        short: Specific event
        mustSupport: false
        binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/datestype'}
        isSummary: false
        index: 17
      when:
        isModifier: false
        short: Occurance date or period
        mustSupport: false
        choices: []
        isSummary: false
        index: 19
    required: [when, type]
  insurer: {isModifier: false, short: Party responsible for reimbursement, mustSupport: false, isSummary: true, index: 8}
  fundsReserve:
    isModifier: false
    short: Funds reserved status
    mustSupport: false
    binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/fundsreserve'}
    isSummary: false
    index: 115
  status:
    isModifier: true
    short: active | cancelled | draft | entered-in-error
    mustSupport: false
    binding: {strength: required, valueSet: 'http://hl7.org/fhir/ValueSet/fm-status|5.0.0'}
    isModifierReason: This element is labeled as a modifier because it is a status element that contains status entered-in-error which means that the resource should not be treated as valid
    isSummary: true
    index: 2
  identifier: {isModifier: false, short: Business Identifier for a claim response, mustSupport: false, array: true, isSummary: false, index: 0}
  error:
    isModifier: false
    short: Processing errors
    mustSupport: false
    array: true
    isSummary: false
    index: 130
    elements:
      itemSequence: {isModifier: false, short: Item sequence number, mustSupport: false, isSummary: false, index: 131}
      detailSequence: {isModifier: false, short: Detail sequence number, mustSupport: false, isSummary: false, index: 132}
      subDetailSequence: {isModifier: false, short: Subdetail sequence number, mustSupport: false, isSummary: false, index: 133}
      code:
        isModifier: false
        short: Error code detailing processing issues
        mustSupport: false
        binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/adjudication-error'}
        isSummary: true
        index: 134
      expression: {isModifier: false, short: FHIRPath of element(s) related to issue, mustSupport: false, array: true, isSummary: true, index: 135}
    required: [code]
  form: {isModifier: false, short: Printed reference or actual form, mustSupport: false, isSummary: false, index: 117}
  subType:
    isModifier: false
    short: More granular claim type
    mustSupport: false
    binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/claim-subtype'}
    isSummary: false
    index: 4
  formCode:
    isModifier: false
    short: Printed form identifier
    mustSupport: false
    binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/forms'}
    isSummary: false
    index: 116
  addItem:
    isModifier: false
    short: Insurer added line items
    mustSupport: false
    array: true
    isSummary: false
    index: 49
    elements:
      request: {isModifier: false, short: Request or Referral for Service, mustSupport: false, array: true, isSummary: false, index: 58}
      modifier:
        isModifier: false
        short: Service/Product billing modifiers
        mustSupport: false
        array: true
        binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/claim-modifiers'}
        isSummary: false
        index: 59
      revenue:
        isModifier: false
        short: Revenue or cost center code
        mustSupport: false
        binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/ex-revenue-center'}
        isSummary: false
        index: 55
      adjudication:
        elementReference: ['http://hl7.org/fhir/StructureDefinition/ClaimResponse', elements, item, elements, adjudication]
        isModifier: false
        short: Added items adjudication
        mustSupport: false
        array: true
        isSummary: false
        index: 75
      subdetailSequence: {isModifier: false, short: Subdetail sequence number, mustSupport: false, array: true, isSummary: false, index: 52}
      productOrServiceEnd:
        isModifier: false
        short: End of a range of codes
        mustSupport: false
        binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/service-uscls'}
        isSummary: false
        index: 57
      traceNumber: {isModifier: false, short: Number for tracking, mustSupport: false, array: true, isSummary: false, index: 53}
      itemSequence: {isModifier: false, short: Item sequence number, mustSupport: false, array: true, isSummary: false, index: 50}
      net: {isModifier: false, short: Total item cost, mustSupport: false, isSummary: false, index: 69}
      serviced:
        isModifier: false
        short: Date or dates of service or product delivery
        mustSupport: false
        choices: []
        isSummary: false
        index: 62
      detailSequence: {isModifier: false, short: Detail sequence number, mustSupport: false, array: true, isSummary: false, index: 51}
      tax: {isModifier: false, short: Total tax, mustSupport: false, isSummary: false, index: 68}
      productOrService:
        isModifier: false
        short: Billing, service, product, or drug code
        mustSupport: false
        binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/service-uscls'}
        isSummary: false
        index: 56
      programCode:
        isModifier: false
        short: Program the product or service is provided under
        mustSupport: false
        array: true
        binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/ex-program-code'}
        isSummary: false
        index: 60
      factor: {isModifier: false, short: Price scaling factor, mustSupport: false, isSummary: false, index: 67}
      bodySite:
        isModifier: false
        short: Anatomical location
        mustSupport: false
        array: true
        isSummary: false
        index: 70
        elements:
          site:
            min: 1
            isModifier: false
            short: Location
            index: 71
            mustSupport: false
            array: true
            binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/tooth'}
            isSummary: false
          subSite:
            isModifier: false
            short: Sub-location
            mustSupport: false
            array: true
            binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/surface'}
            isSummary: false
            index: 72
        required: [site]
      quantity: {isModifier: false, short: Count of products or services, mustSupport: false, isSummary: false, index: 65}
      location:
        isModifier: false
        short: Place of service or where product was supplied
        mustSupport: false
        choices: []
        isSummary: false
        index: 64
      provider: {isModifier: false, short: Authorized providers, mustSupport: false, array: true, isSummary: false, index: 54}
      noteNumber: {isModifier: false, short: Applicable note numbers, mustSupport: false, array: true, isSummary: false, index: 73}
      unitPrice: {isModifier: false, short: 'Fee, charge or cost per item', mustSupport: false, isSummary: false, index: 66}
      reviewOutcome:
        elementReference: ['http://hl7.org/fhir/StructureDefinition/ClaimResponse', elements, item, elements, reviewOutcome]
        isModifier: false
        short: Added items adjudication results
        mustSupport: false
        isSummary: false
        index: 74
      detail:
        isModifier: false
        short: Insurer added line details
        mustSupport: false
        array: true
        isSummary: false
        index: 76
        elements:
          modifier:
            isModifier: false
            short: Service/Product billing modifiers
            mustSupport: false
            array: true
            binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/claim-modifiers'}
            isSummary: false
            index: 81
          revenue:
            isModifier: false
            short: Revenue or cost center code
            mustSupport: false
            binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/ex-revenue-center'}
            isSummary: false
            index: 78
          adjudication:
            elementReference: ['http://hl7.org/fhir/StructureDefinition/ClaimResponse', elements, item, elements, adjudication]
            isModifier: false
            short: Added items detail adjudication
            mustSupport: false
            array: true
            isSummary: false
            index: 89
          productOrServiceEnd:
            isModifier: false
            short: End of a range of codes
            mustSupport: false
            binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/service-uscls'}
            isSummary: false
            index: 80
          traceNumber: {isModifier: false, short: Number for tracking, mustSupport: false, array: true, isSummary: false, index: 77}
          net: {isModifier: false, short: Total item cost, mustSupport: false, isSummary: false, index: 86}
          tax: {isModifier: false, short: Total tax, mustSupport: false, isSummary: false, index: 85}
          productOrService:
            isModifier: false
            short: Billing, service, product, or drug code
            mustSupport: false
            binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/service-uscls'}
            isSummary: false
            index: 79
          factor: {isModifier: false, short: Price scaling factor, mustSupport: false, isSummary: false, index: 84}
          subDetail:
            isModifier: false
            short: Insurer added line items
            mustSupport: false
            array: true
            isSummary: false
            index: 90
            elements:
              modifier:
                isModifier: false
                short: Service/Product billing modifiers
                mustSupport: false
                array: true
                binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/claim-modifiers'}
                isSummary: false
                index: 95
              revenue:
                isModifier: false
                short: Revenue or cost center code
                mustSupport: false
                binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/ex-revenue-center'}
                isSummary: false
                index: 92
              adjudication:
                elementReference: ['http://hl7.org/fhir/StructureDefinition/ClaimResponse', elements, item, elements, adjudication]
                isModifier: false
                short: Added items subdetail adjudication
                mustSupport: false
                array: true
                isSummary: false
                index: 103
              productOrServiceEnd:
                isModifier: false
                short: End of a range of codes
                mustSupport: false
                binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/service-uscls'}
                isSummary: false
                index: 94
              traceNumber: {isModifier: false, short: Number for tracking, mustSupport: false, array: true, isSummary: false, index: 91}
              net: {isModifier: false, short: Total item cost, mustSupport: false, isSummary: false, index: 100}
              tax: {isModifier: false, short: Total tax, mustSupport: false, isSummary: false, index: 99}
              productOrService:
                isModifier: false
                short: Billing, service, product, or drug code
                mustSupport: false
                binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/service-uscls'}
                isSummary: false
                index: 93
              factor: {isModifier: false, short: Price scaling factor, mustSupport: false, isSummary: false, index: 98}
              quantity: {isModifier: false, short: Count of products or services, mustSupport: false, isSummary: false, index: 96}
              noteNumber: {isModifier: false, short: Applicable note numbers, mustSupport: false, array: true, isSummary: false, index: 101}
              unitPrice: {isModifier: false, short: 'Fee, charge or cost per item', mustSupport: false, isSummary: false, index: 97}
              reviewOutcome:
                elementReference: ['http://hl7.org/fhir/StructureDefinition/ClaimResponse', elements, item, elements, reviewOutcome]
                isModifier: false
                short: Added items subdetail level adjudication results
                mustSupport: false
                isSummary: false
                index: 102
          quantity: {isModifier: false, short: Count of products or services, mustSupport: false, isSummary: false, index: 82}
          noteNumber: {isModifier: false, short: Applicable note numbers, mustSupport: false, array: true, isSummary: false, index: 87}
          unitPrice: {isModifier: false, short: 'Fee, charge or cost per item', mustSupport: false, isSummary: false, index: 83}
          reviewOutcome:
            elementReference: ['http://hl7.org/fhir/StructureDefinition/ClaimResponse', elements, item, elements, reviewOutcome]
            isModifier: false
            short: Added items detail level adjudication results
            mustSupport: false
            isSummary: false
            index: 88
  decision:
    isModifier: false
    short: Result of the adjudication
    mustSupport: false
    binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/claim-decision'}
    isSummary: true
    index: 12
class: resource
kind: resource
url: http://hl7.org/fhir/StructureDefinition/ClaimResponse
base: http://hl7.org/fhir/StructureDefinition/DomainResource
version: 5.0.0
required: [created, status, type, patient, use, outcome]