ClaimResponse
FinancialThis resource provides the adjudication details from the processing of a Claim resource.
| Path | Card. | Type | Description & Constraints |
|---|---|---|---|
| ClaimResponse | 0..* | — | Response to a claim predetermination or preauthorization |
| .idΣ | 0..1 | String | Logical id of this artifact |
| .metaΣ | 0..1 | Meta | Metadata about the resource |
| .implicitRules?!Σ | 0..1 | uri | A set of rules under which this content was created |
| .language | 0..1 | code | Language of the resource content Bindinglanguages(preferred) |
| .text | 0..1 | Narrative | Text summary of the resource, for human interpretation |
| .contained | 0..* | Resource | Contained, inline Resources |
| .extension | 0..* | Extension | Additional content defined by implementations |
| .modifierExtension?! | 0..* | Extension | Extensions that cannot be ignored |
| .identifier | 0..* | Identifier | Business Identifier for a claim response |
| .status?!Σ | 1..1 | code | active | cancelled | draft | entered-in-error Bindingfm-status(required) |
| .typeΣ | 1..1 | CodeableConcept | More granular claim type Bindingclaim-type(extensible) |
| .subType | 0..1 | CodeableConcept | More granular claim type Bindingclaim-subtype(example) |
| .useΣ | 1..1 | code | claim | preauthorization | predetermination Bindingclaim-use(required) |
| .patientΣ | 1..1 | Reference(Patient) | The recipient of the products and services |
| .createdΣ | 1..1 | dateTime | Response creation date |
| .insurerΣ | 1..1 | Reference(Organization) | Party responsible for reimbursement |
| .requestor | 0..1 | Reference(Practitioner | PractitionerRole | Organization) | Party responsible for the claim |
| .requestΣ | 0..1 | Reference(Claim) | Id of resource triggering adjudication |
| .outcomeΣ | 1..1 | code | queued | complete | error | partial Bindingremittance-outcome(required) |
| .disposition | 0..1 | string | Disposition Message |
| .preAuthRef | 0..1 | string | Preauthorization reference |
| .preAuthPeriod | 0..1 | Period | Preauthorization reference effective period |
| .payeeType | 0..1 | CodeableConcept | Party to be paid any benefits payable Bindingpayeetype(example) |
| .item | 0..* | BackboneElement | Adjudication for claim line items |
| .id | 0..1 | String | Unique id for inter-element referencing |
| .extension | 0..* | Extension | Additional content defined by implementations |
| .modifierExtension?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| .itemSequence | 1..1 | positiveInt | Claim item instance identifier |
| .noteNumber | 0..* | positiveInt | Applicable note numbers |
| .adjudication | 1..* | BackboneElement | Adjudication details |
| .id | 0..1 | String | Unique id for inter-element referencing |
| .extension | 0..* | Extension | Additional content defined by implementations |
| .modifierExtension?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| .category | 1..1 | CodeableConcept | Type of adjudication information Bindingadjudication(example) |
| .reason | 0..1 | CodeableConcept | Explanation of adjudication outcome Bindingadjudication-reason(example) |
| .amount | 0..1 | Money | Monetary amount |
| .value | 0..1 | decimal | Non-monetary value |
| .detail | 0..* | BackboneElement | Adjudication for claim details |
| .id | 0..1 | String | Unique id for inter-element referencing |
| .extension | 0..* | Extension | Additional content defined by implementations |
| .modifierExtension?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| .detailSequence | 1..1 | positiveInt | Claim detail instance identifier |
| .noteNumber | 0..* | positiveInt | Applicable note numbers |
| .adjudication | 1..* | — | Detail level adjudication details |
| .subDetail | 0..* | BackboneElement | Adjudication for claim sub-details |
| .id | 0..1 | String | Unique id for inter-element referencing |
| .extension | 0..* | Extension | Additional content defined by implementations |
| .modifierExtension?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| .subDetailSequence | 1..1 | positiveInt | Claim sub-detail instance identifier |
| .noteNumber | 0..* | positiveInt | Applicable note numbers |
| .adjudication | 0..* | — | Subdetail level adjudication details |
| .addItem | 0..* | BackboneElement | Insurer added line items |
| .id | 0..1 | String | Unique id for inter-element referencing |
| .extension | 0..* | Extension | Additional content defined by implementations |
| .modifierExtension?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| .itemSequence | 0..* | positiveInt | Item sequence number |
| .detailSequence | 0..* | positiveInt | Detail sequence number |
| .subdetailSequence | 0..* | positiveInt | Subdetail sequence number |
| .provider | 0..* | Reference(Practitioner | PractitionerRole | Organization) | Authorized providers |
| .productOrService | 1..1 | CodeableConcept | Billing, service, product, or drug code Bindingservice-uscls(example) |
| .modifier | 0..* | CodeableConcept | Service/Product billing modifiers Bindingclaim-modifiers(example) |
| .programCode | 0..* | CodeableConcept | Program the product or service is provided under Bindingex-program-code(example) |
| .serviced[x] | 0..1 | date | Period | Date or dates of service or product delivery |
| .location[x] | 0..1 | CodeableConcept | Address | Reference(Location) | Place of service or where product was supplied Bindingservice-place(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 |
| .net | 0..1 | Money | Total item cost |
| .bodySite | 0..1 | CodeableConcept | Anatomical location Bindingtooth(example) |
| .subSite | 0..* | CodeableConcept | Anatomical sub-location Bindingsurface(example) |
| .noteNumber | 0..* | positiveInt | Applicable note numbers |
| .adjudication | 1..* | — | Added items adjudication |
| .detail | 0..* | BackboneElement | Insurer added line details |
| .id | 0..1 | String | Unique id for inter-element referencing |
| .extension | 0..* | Extension | Additional content defined by implementations |
| .modifierExtension?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| .productOrService | 1..1 | CodeableConcept | Billing, service, product, or drug code Bindingservice-uscls(example) |
| .modifier | 0..* | CodeableConcept | Service/Product billing modifiers Bindingclaim-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 |
| .net | 0..1 | Money | Total item cost |
| .noteNumber | 0..* | positiveInt | Applicable note numbers |
| .adjudication | 1..* | — | Added items detail adjudication |
| .subDetail | 0..* | BackboneElement | Insurer added line items |
| .id | 0..1 | String | Unique id for inter-element referencing |
| .extension | 0..* | Extension | Additional content defined by implementations |
| .modifierExtension?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| .productOrService | 1..1 | CodeableConcept | Billing, service, product, or drug code Bindingservice-uscls(example) |
| .modifier | 0..* | CodeableConcept | Service/Product billing modifiers Bindingclaim-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 |
| .net | 0..1 | Money | Total item cost |
| .noteNumber | 0..* | positiveInt | Applicable note numbers |
| .adjudication | 1..* | — | Added items detail adjudication |
| .adjudication | 0..* | — | Header-level adjudication |
| .totalΣ | 0..* | BackboneElement | Adjudication totals |
| .id | 0..1 | String | Unique id for inter-element referencing |
| .extension | 0..* | Extension | Additional content defined by implementations |
| .modifierExtension?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| .categoryΣ | 1..1 | CodeableConcept | Type of adjudication information Bindingadjudication(example) |
| .amountΣ | 1..1 | Money | Financial total for the category |
| .payment | 0..1 | BackboneElement | Payment Details |
| .id | 0..1 | String | Unique id for inter-element referencing |
| .extension | 0..* | Extension | Additional content defined by implementations |
| .modifierExtension?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| .type | 1..1 | CodeableConcept | Partial or complete payment Bindingex-paymenttype(example) |
| .adjustment | 0..1 | Money | Payment adjustment for non-claim issues |
| .adjustmentReason | 0..1 | CodeableConcept | Explanation for the adjustment Bindingpayment-adjustment-reason(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 Bindingfundsreserve(example) |
| .formCode | 0..1 | CodeableConcept | Printed form identifier Bindingforms(example) |
| .form | 0..1 | Attachment | Printed reference or actual form |
| .processNote | 0..* | BackboneElement | Note concerning adjudication |
| .id | 0..1 | String | Unique id for inter-element referencing |
| .extension | 0..* | Extension | Additional content defined by implementations |
| .modifierExtension?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| .number | 0..1 | positiveInt | Note instance identifier |
| .type | 0..1 | code | display | print | printoper Bindingnote-type(required) |
| .text | 1..1 | string | Note explanatory text |
| .language | 0..1 | CodeableConcept | Language of the text Bindinglanguages(preferred) |
| .communicationRequest | 0..* | Reference(CommunicationRequest) | Request for additional information |
| .insurance | 0..* | BackboneElement | Patient insurance information |
| .id | 0..1 | String | Unique id for inter-element referencing |
| .extension | 0..* | Extension | Additional content defined by implementations |
| .modifierExtension?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| .sequence | 1..1 | positiveInt | Insurance instance identifier |
| .focal | 1..1 | boolean | Coverage to be used for adjudication |
| .coverage | 1..1 | Reference(Coverage) | Insurance information |
| .businessArrangement | 0..1 | string | Additional provider contract number |
| .claimResponse | 0..1 | Reference(ClaimResponse) | Adjudication results |
| .error | 0..* | BackboneElement | Processing errors |
| .id | 0..1 | String | Unique id for inter-element referencing |
| .extension | 0..* | Extension | Additional content defined by implementations |
| .modifierExtension?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| .itemSequence | 0..1 | positiveInt | Item sequence number |
| .detailSequence | 0..1 | positiveInt | Detail sequence number |
| .subDetailSequence | 0..1 | positiveInt | Subdetail sequence number |
| .code | 1..1 | CodeableConcept | Error code detailing processing issues Bindingadjudication-error(example) |