Resources
ClaimResponse
Resources
ClaimResponse
This resource provides the adjudication details from the processing of a Claim resource.
Properties
| Name | Required | Type | Description |
|---|---|---|---|
| identifier | No | Identifier[] | Business Identifier for a claim response |
| status | Yes | code | active / cancelled / draft / entered-in-error |
| type | Yes | CodeableConcept | More granular claim type |
| subType | No | CodeableConcept | More granular claim type |
| use | Yes | code | claim / preauthorization / predetermination |
| patient | Yes | Reference<Patient> | The recipient of the products and services |
| created | Yes | dateTime | Response creation date |
| insurer | Yes | Reference<Organization> | Party responsible for reimbursement |
| requestor | No | Reference<Practitioner / PractitionerRole / Organization> | Party responsible for the claim |
| request | No | Reference<Claim> | Id of resource triggering adjudication |
| outcome | Yes | code | queued / complete / error / partial |
| disposition | No | string | Disposition Message |
| preAuthRef | No | string | Preauthorization reference |
| preAuthPeriod | No | Period | Preauthorization reference effective period |
| payeeType | No | CodeableConcept | Party to be paid any benefits payable |
| item | No | ClaimResponseItem | Adjudication for claim line items |
| - id | No | string | Unique id for inter-element referencing |
| - extension | No | Extension[] | Additional content defined by implementations |
| - modifierExtension | No | Extension[] | Extensions that cannot be ignored even if unrecognized |
| - itemSequence | Yes | positiveInt | Claim item instance identifier |
| - noteNumber | No | positiveInt[] | Applicable note numbers |
| - adjudication | Yes | ClaimResponseItemAdjudication | Adjudication details |
| - id | No | string | Unique id for inter-element referencing |
| - extension | No | Extension[] | Additional content defined by implementations |
| - modifierExtension | No | Extension[] | Extensions that cannot be ignored even if unrecognized |
| - category | Yes | CodeableConcept | Type of adjudication information |
| - reason | No | CodeableConcept | Explanation of adjudication outcome |
| - amount | No | Money | Monetary amount |
| - value | No | decimal | Non-monetary value |
| - detail | No | ClaimResponseItemDetail | Adjudication for claim details |
| - id | No | string | Unique id for inter-element referencing |
| - extension | No | Extension[] | Additional content defined by implementations |
| - modifierExtension | No | Extension[] | Extensions that cannot be ignored even if unrecognized |
| - detailSequence | Yes | positiveInt | Claim detail instance identifier |
| - noteNumber | No | positiveInt[] | Applicable note numbers |
| - adjudication | Yes | [] | Detail level adjudication details |
| - subDetail | No | ClaimResponseItemDetailSubDetail | Adjudication for claim sub-details |
| - id | No | string | Unique id for inter-element referencing |
| - extension | No | Extension[] | Additional content defined by implementations |
| - modifierExtension | No | Extension[] | Extensions that cannot be ignored even if unrecognized |
| - subDetailSequence | Yes | positiveInt | Claim sub-detail instance identifier |
| - noteNumber | No | positiveInt[] | Applicable note numbers |
| - adjudication | No | [] | Subdetail level adjudication details |
| addItem | No | ClaimResponseAddItem | Insurer added line items |
| - id | No | string | Unique id for inter-element referencing |
| - extension | No | Extension[] | Additional content defined by implementations |
| - modifierExtension | No | Extension[] | Extensions that cannot be ignored even if unrecognized |
| - itemSequence | No | positiveInt[] | Item sequence number |
| - detailSequence | No | positiveInt[] | Detail sequence number |
| - subdetailSequence | No | positiveInt[] | Subdetail sequence number |
| - provider | No | Reference<Practitioner / PractitionerRole / Organization>[] | Authorized providers |
| - productOrService | Yes | CodeableConcept | Billing, service, product, or drug code |
| - modifier | No | CodeableConcept[] | Service/Product billing modifiers |
| - programCode | No | CodeableConcept[] | Program the product or service is provided under |
| - serviced[x] | No | date, Period | Date or dates of service or product delivery |
| - location[x] | No | CodeableConcept, Address, Reference<Location> | Place of service or where product was supplied |
| - quantity | No | Quantity | Count of products or services |
| - unitPrice | No | Money | Fee, charge or cost per item |
| - factor | No | decimal | Price scaling factor |
| - net | No | Money | Total item cost |
| - bodySite | No | CodeableConcept | Anatomical location |
| - subSite | No | CodeableConcept[] | Anatomical sub-location |
| - noteNumber | No | positiveInt[] | Applicable note numbers |
| - adjudication | Yes | [] | Added items adjudication |
| - detail | No | ClaimResponseAddItemDetail | Insurer added line details |
| - id | No | string | Unique id for inter-element referencing |
| - extension | No | Extension[] | Additional content defined by implementations |
| - modifierExtension | No | Extension[] | Extensions that cannot be ignored even if unrecognized |
| - productOrService | Yes | CodeableConcept | Billing, service, product, or drug code |
| - modifier | No | CodeableConcept[] | Service/Product billing modifiers |
| - quantity | No | Quantity | Count of products or services |
| - unitPrice | No | Money | Fee, charge or cost per item |
| - factor | No | decimal | Price scaling factor |
| - net | No | Money | Total item cost |
| - noteNumber | No | positiveInt[] | Applicable note numbers |
| - adjudication | Yes | [] | Added items detail adjudication |
| - subDetail | No | ClaimResponseAddItemDetailSubDetail | Insurer added line items |
| - id | No | string | Unique id for inter-element referencing |
| - extension | No | Extension[] | Additional content defined by implementations |
| - modifierExtension | No | Extension[] | Extensions that cannot be ignored even if unrecognized |
| - productOrService | Yes | CodeableConcept | Billing, service, product, or drug code |
| - modifier | No | CodeableConcept[] | Service/Product billing modifiers |
| - quantity | No | Quantity | Count of products or services |
| - unitPrice | No | Money | Fee, charge or cost per item |
| - factor | No | decimal | Price scaling factor |
| - net | No | Money | Total item cost |
| - noteNumber | No | positiveInt[] | Applicable note numbers |
| - adjudication | Yes | [] | Added items detail adjudication |
| adjudication | No | [] | Header-level adjudication |
| total | No | ClaimResponseTotal | Adjudication totals |
| - id | No | string | Unique id for inter-element referencing |
| - extension | No | Extension[] | Additional content defined by implementations |
| - modifierExtension | No | Extension[] | Extensions that cannot be ignored even if unrecognized |
| - category | Yes | CodeableConcept | Type of adjudication information |
| - amount | Yes | Money | Financial total for the category |
| payment | No | ClaimResponsePayment | Payment Details |
| - id | No | string | Unique id for inter-element referencing |
| - extension | No | Extension[] | Additional content defined by implementations |
| - modifierExtension | No | Extension[] | Extensions that cannot be ignored even if unrecognized |
| - type | Yes | CodeableConcept | Partial or complete payment |
| - adjustment | No | Money | Payment adjustment for non-claim issues |
| - adjustmentReason | No | CodeableConcept | Explanation for the adjustment |
| - date | No | date | Expected date of payment |
| - amount | Yes | Money | Payable amount after adjustment |
| - identifier | No | Identifier | Business identifier for the payment |
| fundsReserve | No | CodeableConcept | Funds reserved status |
| formCode | No | CodeableConcept | Printed form identifier |
| form | No | Attachment | Printed reference or actual form |
| processNote | No | ClaimResponseProcessNote | Note concerning adjudication |
| - id | No | string | Unique id for inter-element referencing |
| - extension | No | Extension[] | Additional content defined by implementations |
| - modifierExtension | No | Extension[] | Extensions that cannot be ignored even if unrecognized |
| - number | No | positiveInt | Note instance identifier |
| - type | No | code | display / print / printoper |
| - text | Yes | string | Note explanatory text |
| - language | No | CodeableConcept | Language of the text |
| communicationRequest | No | Reference<CommunicationRequest>[] | Request for additional information |
| insurance | No | ClaimResponseInsurance | Patient insurance information |
| - id | No | string | Unique id for inter-element referencing |
| - extension | No | Extension[] | Additional content defined by implementations |
| - modifierExtension | No | Extension[] | Extensions that cannot be ignored even if unrecognized |
| - sequence | Yes | positiveInt | Insurance instance identifier |
| - focal | Yes | boolean | Coverage to be used for adjudication |
| - coverage | Yes | Reference<Coverage> | Insurance information |
| - businessArrangement | No | string | Additional provider contract number |
| - claimResponse | No | Reference<ClaimResponse> | Adjudication results |
| error | No | ClaimResponseError | Processing errors |
| - id | No | string | Unique id for inter-element referencing |
| - extension | No | Extension[] | Additional content defined by implementations |
| - modifierExtension | No | Extension[] | Extensions that cannot be ignored even if unrecognized |
| - itemSequence | No | positiveInt | Item sequence number |
| - detailSequence | No | positiveInt | Detail sequence number |
| - subDetailSequence | No | positiveInt | Subdetail sequence number |
| - code | Yes | CodeableConcept | Error code detailing processing issues |
Search Parameters
| Name | Type | Description | Expression |
|---|---|---|---|
| created | date | The creation date | ClaimResponse.created |
| disposition | string | The contents of the disposition message | ClaimResponse.disposition |
| identifier | token | The identity of the ClaimResponse | ClaimResponse.identifier |
| insurer | reference | The organization which generated this resource | ClaimResponse.insurer |
| outcome | token | The processing outcome | ClaimResponse.outcome |
| patient | reference | The subject of care | ClaimResponse.patient |
| payment-date | date | The expected payment date | ClaimResponse.payment.date |
| request | reference | The claim reference | ClaimResponse.request |
| requestor | reference | The Provider of the claim | ClaimResponse.requestor |
| status | token | The status of the ClaimResponse | ClaimResponse.status |
| use | token | The type of claim | ClaimResponse.use |
Inherited Properties
| Name | Required | Type | Description |
|---|---|---|---|
| id | No | string | Logical id of this artifact |
| meta | No | Meta | Metadata about the resource |
| implicitRules | No | uri | A set of rules under which this content was created |
| language | No | code | Language of the resource content |
| text | No | Narrative | Text summary of the resource, for human interpretation |
| contained | No | Resource[] | Contained, inline Resources |
| extension | No | Extension[] | Additional content defined by implementations |
| modifierExtension | No | Extension[] | Extensions that cannot be ignored |
To view the FHIR specification for this resource, see ClaimResponse.