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

description: This resource provides the adjudication details from the processing of a Claim resource.
derivation: specialization
name: ClaimResponse
type: ClaimResponse
elements:
  patient: {short: The recipient of the products and services, isSummary: true, index: 5}
  requestor: {short: Party responsible for the claim, index: 8}
  payeeType:
    short: Party to be paid any benefits payable
    binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/payeetype'}
    index: 14
  insurance:
    short: Patient insurance information
    array: true
    index: 89
    elements:
      sequence: {short: Insurance instance identifier, index: 90}
      focal: {short: Coverage to be used for adjudication, index: 91}
      coverage: {short: Insurance information, index: 92}
      businessArrangement: {short: Additional provider contract number, index: 93}
      claimResponse: {short: Adjudication results, index: 94}
    required: [coverage, focal, sequence]
  request: {short: Id of resource triggering adjudication, isSummary: true, index: 9}
  processNote:
    short: Note concerning adjudication
    array: true
    index: 83
    elements:
      number: {short: Note instance identifier, index: 84}
      type:
        short: display | print | printoper
        binding: {strength: required, valueSet: 'http://hl7.org/fhir/ValueSet/note-type|4.0.1'}
        index: 85
      text: {short: Note explanatory text, index: 86}
      language:
        short: Language of the text
        binding: {strength: preferred, valueSet: 'http://hl7.org/fhir/ValueSet/languages'}
        index: 87
    required: [text]
  preAuthRef: {short: Preauthorization reference, index: 12}
  adjudication:
    elementReference: ['http://hl7.org/fhir/StructureDefinition/ClaimResponse', elements, item, elements, adjudication]
    short: Header-level adjudication
    array: true
    index: 69
  use:
    short: claim | preauthorization | predetermination
    binding: {strength: required, valueSet: 'http://hl7.org/fhir/ValueSet/claim-use|4.0.1'}
    isSummary: true
    index: 4
  payment:
    short: Payment Details
    index: 73
    elements:
      type:
        short: Partial or complete payment
        binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/ex-paymenttype'}
        index: 74
      adjustment: {short: Payment adjustment for non-claim issues, index: 75}
      adjustmentReason:
        short: Explanation for the adjustment
        binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/payment-adjustment-reason'}
        index: 76
      date: {short: Expected date of payment, index: 77}
      amount: {short: Payable amount after adjustment, index: 78}
      identifier: {short: Business identifier for the payment, index: 79}
    required: [type, amount]
  item:
    short: Adjudication for claim line items
    array: true
    index: 15
    elements:
      itemSequence: {short: Claim item instance identifier, index: 16}
      noteNumber: {short: Applicable note numbers, array: true, index: 17}
      adjudication:
        min: 1
        short: Adjudication details
        array: true
        index: 18
        elements:
          category:
            short: Type of adjudication information
            binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/adjudication'}
            index: 19
          reason:
            short: Explanation of adjudication outcome
            binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/adjudication-reason'}
            index: 20
          amount: {short: Monetary amount, index: 21}
          value: {short: Non-monetary value, index: 22}
        required: [category]
      detail:
        short: Adjudication for claim details
        array: true
        index: 23
        elements:
          detailSequence: {short: Claim detail instance identifier, index: 24}
          noteNumber: {short: Applicable note numbers, array: true, index: 25}
          adjudication:
            elementReference: ['http://hl7.org/fhir/StructureDefinition/ClaimResponse', elements, item, elements, adjudication]
            min: 1
            short: Detail level adjudication details
            array: true
            index: 26
          subDetail:
            short: Adjudication for claim sub-details
            array: true
            index: 27
            elements:
              subDetailSequence: {short: Claim sub-detail instance identifier, index: 28}
              noteNumber: {short: Applicable note numbers, array: true, index: 29}
              adjudication:
                elementReference: ['http://hl7.org/fhir/StructureDefinition/ClaimResponse', elements, item, elements, adjudication]
                short: Subdetail level adjudication details
                array: true
                index: 30
            required: [subDetailSequence]
        required: [adjudication, detailSequence]
    required: [adjudication, itemSequence]
  type:
    short: More granular claim type
    binding: {strength: extensible, valueSet: 'http://hl7.org/fhir/ValueSet/claim-type'}
    isSummary: true
    index: 2
  created: {short: Response creation date, isSummary: true, index: 6}
  preAuthPeriod: {short: Preauthorization reference effective period, index: 13}
  outcome:
    short: queued | complete | error | partial
    binding: {strength: required, valueSet: 'http://hl7.org/fhir/ValueSet/remittance-outcome|4.0.1'}
    isSummary: true
    index: 10
  disposition: {short: Disposition Message, index: 11}
  communicationRequest: {short: Request for additional information, array: true, index: 88}
  total:
    short: Adjudication totals
    array: true
    isSummary: true
    index: 70
    elements:
      category:
        short: Type of adjudication information
        binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/adjudication'}
        isSummary: true
        index: 71
      amount: {short: Financial total for the category, isSummary: true, index: 72}
    required: [amount, category]
  insurer: {short: Party responsible for reimbursement, isSummary: true, index: 7}
  fundsReserve:
    short: Funds reserved status
    binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/fundsreserve'}
    index: 80
  status:
    isModifier: true
    short: active | cancelled | draft | entered-in-error
    binding: {strength: required, valueSet: 'http://hl7.org/fhir/ValueSet/fm-status|4.0.1'}
    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: 1
  identifier: {short: Business Identifier for a claim response, array: true, index: 0}
  error:
    short: Processing errors
    array: true
    index: 95
    elements:
      itemSequence: {short: Item sequence number, index: 96}
      detailSequence: {short: Detail sequence number, index: 97}
      subDetailSequence: {short: Subdetail sequence number, index: 98}
      code:
        short: Error code detailing processing issues
        binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/adjudication-error'}
        index: 99
    required: [code]
  form: {short: Printed reference or actual form, index: 82}
  subType:
    short: More granular claim type
    binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/claim-subtype'}
    index: 3
  formCode:
    short: Printed form identifier
    binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/forms'}
    index: 81
  addItem:
    short: Insurer added line items
    array: true
    index: 31
    elements:
      modifier:
        short: Service/Product billing modifiers
        array: true
        binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/claim-modifiers'}
        index: 37
      adjudication:
        elementReference: ['http://hl7.org/fhir/StructureDefinition/ClaimResponse', elements, item, elements, adjudication]
        min: 1
        short: Added items adjudication
        array: true
        index: 50
      subdetailSequence: {short: Subdetail sequence number, array: true, index: 34}
      itemSequence: {short: Item sequence number, array: true, index: 32}
      net: {short: Total item cost, index: 46}
      serviced:
        short: Date or dates of service or product delivery
        choices: []
        index: 40
      detailSequence: {short: Detail sequence number, array: true, index: 33}
      subSite:
        short: Anatomical sub-location
        array: true
        binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/surface'}
        index: 48
      productOrService:
        short: Billing, service, product, or drug code
        binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/service-uscls'}
        index: 36
      programCode:
        short: Program the product or service is provided under
        array: true
        binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/ex-program-code'}
        index: 38
      factor: {short: Price scaling factor, index: 45}
      bodySite:
        short: Anatomical location
        binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/tooth'}
        index: 47
      quantity: {short: Count of products or services, index: 43}
      location:
        short: Place of service or where product was supplied
        choices: []
        index: 42
      provider: {short: Authorized providers, array: true, index: 35}
      noteNumber: {short: Applicable note numbers, array: true, index: 49}
      unitPrice: {short: 'Fee, charge or cost per item', index: 44}
      detail:
        short: Insurer added line details
        array: true
        index: 51
        elements:
          modifier:
            short: Service/Product billing modifiers
            array: true
            binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/claim-modifiers'}
            index: 53
          adjudication:
            elementReference: ['http://hl7.org/fhir/StructureDefinition/ClaimResponse', elements, item, elements, adjudication]
            min: 1
            short: Added items detail adjudication
            array: true
            index: 59
          net: {short: Total item cost, index: 57}
          productOrService:
            short: Billing, service, product, or drug code
            binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/service-uscls'}
            index: 52
          factor: {short: Price scaling factor, index: 56}
          subDetail:
            short: Insurer added line items
            array: true
            index: 60
            elements:
              productOrService:
                short: Billing, service, product, or drug code
                binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/service-uscls'}
                index: 61
              modifier:
                short: Service/Product billing modifiers
                array: true
                binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/claim-modifiers'}
                index: 62
              quantity: {short: Count of products or services, index: 63}
              unitPrice: {short: 'Fee, charge or cost per item', index: 64}
              factor: {short: Price scaling factor, index: 65}
              net: {short: Total item cost, index: 66}
              noteNumber: {short: Applicable note numbers, array: true, index: 67}
              adjudication:
                elementReference: ['http://hl7.org/fhir/StructureDefinition/ClaimResponse', elements, item, elements, adjudication]
                min: 1
                short: Added items detail adjudication
                array: true
                index: 68
            required: [adjudication, productOrService]
          quantity: {short: Count of products or services, index: 54}
          noteNumber: {short: Applicable note numbers, array: true, index: 58}
          unitPrice: {short: 'Fee, charge or cost per item', index: 55}
        required: [adjudication, productOrService]
    required: [adjudication, productOrService]
class: resource
kind: resource
url: http://hl7.org/fhir/StructureDefinition/ClaimResponse
base: http://hl7.org/fhir/StructureDefinition/DomainResource
version: 4.0.1
required: [created, insurer, status, type, patient, use, outcome]