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StructureDefinitionsClaimResponse

http://hl7.org/fhir/StructureDefinition/ClaimResponse|4.0.1

This resource provides the adjudication details from the processing of a Claim resource.
StructureJSONDependenciesFHIRSchemaOther VersionsDependant (0)ElementsSummary
NameFlagsCardTypeDescription & Constraints
ClaimResponse
0..*Response to a claim predetermination or preauthorization
 
identifier
0..*IdentifierBusiness Identifier for a claim response
 
status *
?!Σ
1..1codeactive | cancelled | draft | entered-in-error ClaimResponseStatus (required)
 
type *
Σ
1..1CodeableConceptMore granular claim type ClaimType (extensible)
 
subType
0..1CodeableConceptMore granular claim type ClaimSubType (example)
 
use *
Σ
1..1codeclaim | preauthorization | predetermination Use (required)
 
patient *
Σ
1..1ReferenceThe recipient of the products and services
 
created *
Σ
1..1dateTimeResponse creation date
 
insurer *
Σ
1..1ReferenceParty responsible for reimbursement
 
requestor
0..1ReferenceParty responsible for the claim
 
request
Σ
0..1ReferenceId of resource triggering adjudication
 
outcome *
Σ
1..1codequeued | complete | error | partial RemittanceOutcome (required)
 
disposition
0..1stringDisposition Message
 
preAuthRef
0..1stringPreauthorization reference
 
preAuthPeriod
0..1PeriodPreauthorization reference effective period
 
payeeType
0..1CodeableConceptParty to be paid any benefits payable PayeeType (example)
 
item
0..*BackboneElementAdjudication for claim line items
 
 
itemSequence *
1..1positiveIntClaim item instance identifier
 
 
noteNumber
0..*positiveIntApplicable note numbers
 
 
adjudication *
1..*BackboneElementAdjudication details
 
 
 
category *
1..1CodeableConceptType of adjudication information Adjudication (example)
 
 
 
reason
0..1CodeableConceptExplanation of adjudication outcome AdjudicationReason (example)
 
 
 
amount
0..1MoneyMonetary amount
 
 
 
value
0..1decimalNon-monetary value
 
 
detail
0..*BackboneElementAdjudication for claim details
 
 
 
detailSequence *
1..1positiveIntClaim detail instance identifier
 
 
 
noteNumber
0..*positiveIntApplicable note numbers
 
 
 
adjudication *
1..*Detail level adjudication details
 
 
 
subDetail
0..*BackboneElementAdjudication for claim sub-details
 
 
 
 
subDetailSequence *
1..1positiveIntClaim sub-detail instance identifier
 
 
 
 
noteNumber
0..*positiveIntApplicable note numbers
 
 
 
 
adjudication
0..*Subdetail level adjudication details
 
addItem
0..*BackboneElementInsurer added line items
 
 
itemSequence
0..*positiveIntItem sequence number
 
 
detailSequence
0..*positiveIntDetail sequence number
 
 
subdetailSequence
0..*positiveIntSubdetail sequence number
 
 
provider
0..*ReferenceAuthorized providers
 
 
productOrService *
1..1CodeableConceptBilling, service, product, or drug code ServiceProduct (example)
 
 
modifier
0..*CodeableConceptService/Product billing modifiers Modifiers (example)
 
 
programCode
0..*CodeableConceptProgram the product or service is provided under ProgramCode (example)
 
 
serviced[x]
0..1Date or dates of service or product delivery
 
 
 
servicedDate
0..1date
 
 
 
servicedPeriod
0..1Period
 
 
location[x]
0..1Place of service or where product was supplied ServicePlace (example)
 
 
 
locationCodeableConcept
0..1CodeableConcept ServicePlace (example)
 
 
 
locationAddress
0..1Address ServicePlace (example)
 
 
 
locationReference
0..1Reference ServicePlace (example)
 
 
quantity
0..1QuantityCount of products or services
 
 
unitPrice
0..1MoneyFee, charge or cost per item
 
 
factor
0..1decimalPrice scaling factor
 
 
net
0..1MoneyTotal item cost
 
 
bodySite
0..1CodeableConceptAnatomical location OralSites (example)
 
 
subSite
0..*CodeableConceptAnatomical sub-location Surface (example)
 
 
noteNumber
0..*positiveIntApplicable note numbers
 
 
adjudication *
1..*Added items adjudication
 
 
detail
0..*BackboneElementInsurer added line details
 
 
 
productOrService *
1..1CodeableConceptBilling, service, product, or drug code ServiceProduct (example)
 
 
 
modifier
0..*CodeableConceptService/Product billing modifiers Modifiers (example)
 
 
 
quantity
0..1QuantityCount of products or services
 
 
 
unitPrice
0..1MoneyFee, charge or cost per item
 
 
 
factor
0..1decimalPrice scaling factor
 
 
 
net
0..1MoneyTotal item cost
 
 
 
noteNumber
0..*positiveIntApplicable note numbers
 
 
 
adjudication *
1..*Added items detail adjudication
 
 
 
subDetail
0..*BackboneElementInsurer added line items
 
 
 
 
productOrService *
1..1CodeableConceptBilling, service, product, or drug code ServiceProduct (example)
 
 
 
 
modifier
0..*CodeableConceptService/Product billing modifiers Modifiers (example)
 
 
 
 
quantity
0..1QuantityCount of products or services
 
 
 
 
unitPrice
0..1MoneyFee, charge or cost per item
 
 
 
 
factor
0..1decimalPrice scaling factor
 
 
 
 
net
0..1MoneyTotal item cost
 
 
 
 
noteNumber
0..*positiveIntApplicable note numbers
 
 
 
 
adjudication *
1..*Added items detail adjudication
 
adjudication
0..*Header-level adjudication
 
total
Σ
0..*BackboneElementAdjudication totals
 
 
category *
Σ
1..1CodeableConceptType of adjudication information Adjudication (example)
 
 
amount *
Σ
1..1MoneyFinancial total for the category
 
payment
0..1BackboneElementPayment Details
 
 
type *
1..1CodeableConceptPartial or complete payment PaymentType (example)
 
 
adjustment
0..1MoneyPayment adjustment for non-claim issues
 
 
adjustmentReason
0..1CodeableConceptExplanation for the adjustment PaymentAdjustmentReason (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 FundsReserve (example)
 
formCode
0..1CodeableConceptPrinted form identifier Forms (example)
 
form
0..1AttachmentPrinted reference or actual form
 
processNote
0..*BackboneElementNote concerning adjudication
 
 
number
0..1positiveIntNote instance identifier
 
 
type
0..1codedisplay | print | printoper NoteType (required)
 
 
text *
1..1stringNote explanatory text
 
 
language
0..1CodeableConceptLanguage of the text Language (preferred)
 
communicationRequest
0..*ReferenceRequest for additional information
 
insurance
0..*BackboneElementPatient insurance information
 
 
sequence *
1..1positiveIntInsurance instance identifier
 
 
focal *
1..1booleanCoverage to be used for adjudication
 
 
coverage *
1..1ReferenceInsurance information
 
 
businessArrangement
0..1stringAdditional provider contract number
 
 
claimResponse
0..1ReferenceAdjudication results
 
error
0..*BackboneElementProcessing errors
 
 
itemSequence
0..1positiveIntItem sequence number
 
 
detailSequence
0..1positiveIntDetail sequence number
 
 
subDetailSequence
0..1positiveIntSubdetail sequence number
 
 
code *
1..1CodeableConceptError code detailing processing issues AdjudicationError (example)