Resource type: claimresponse

Description

This resource provides the adjudication details from the processing of a Claim resource.

Elements

PathShortDefinitionComments
Response to a claim predetermination or preauthorizationThis resource provides the adjudication details from the processing of a Claim resource.
identifierBusiness Identifier for a claim responseA unique identifier assigned to this claim response.
statusactive | cancelled | draft | entered-in-errorThe status of the resource instance.This element is labeled as a modifier because the status contains codes that mark the resource as not currently valid.
typeMore granular claim typeA finer grained suite of claim type codes which may convey additional information such as Inpatient vs Outpatient and/or a specialty service.This may contain the local bill type codes, for example the US UB-04 bill type code or the CMS bill type.
subTypeMore granular claim typeA finer grained suite of claim type codes which may convey additional information such as Inpatient vs Outpatient and/or a specialty service.This may contain the local bill type codes, for example the US UB-04 bill type code or the CMS bill type.
useclaim | preauthorization | predeterminationA code to indicate whether the nature of the request is: to request adjudication of products and services previously rendered; or requesting authorization and adjudication for provision in the future; or requesting the non-binding adjudication of the listed products and services which could be provided in the future.
patientThe recipient of the products and servicesThe party to whom the professional services and/or products have been supplied or are being considered and for whom actual for facast reimburement is sought.
createdResponse creation dateThe date this resource was created.
insurerParty responsible for reimbursementThe party responsible for authorization, adjudication and reimbursement.
requestorParty responsible for the claimThe provider which is responsible for the claim, predetermination or preauthorization.Typically this field would be 1..1 where this party is responsible for the claim but not necessarily professionally responsible for the provision of the individual products and services listed below.
requestId of resource triggering adjudicationOriginal request resource reference.
outcomequeued | complete | error | partialThe outcome of the claim, predetermination, or preauthorization processing.The resource may be used to indicate that: the request has been held (queued) for processing; that it has been processed and errors found (error); that no errors were found and that some of the adjudication has been undertaken (partial) or that all of the adjudication has been undertaken (complete).
dispositionDisposition MessageA human readable description of the status of the adjudication.
preAuthRefPreauthorization referenceReference from the Insurer which is used in later communications which refers to this adjudication.This value is only present on preauthorization adjudications.
preAuthPeriodPreauthorization reference effective periodThe time frame during which this authorization is effective.
payeeTypeParty to be paid any benefits payableType of Party to be reimbursed: subscriber, provider, other.
itemAdjudication for claim line itemsA claim line. Either a simple (a product or service) or a 'group' of details which can also be a simple items or groups of sub-details.
item.idUnique id for inter-element referencingUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
item.extensionAdditional content defined by implementationsMay be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
item.modifierExtensionExtensions that cannot be ignored even if unrecognizedMay be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
item.itemSequenceClaim item instance identifierA number to uniquely reference the claim item entries.
item.noteNumberApplicable note numbersThe numbers associated with notes below which apply to the adjudication of this item.
item.adjudicationAdjudication detailsIf this item is a group then the values here are a summary of the adjudication of the detail items. If this item is a simple product or service then this is the result of the adjudication of this item.
item.adjudication.idUnique id for inter-element referencingUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
item.adjudication.extensionAdditional content defined by implementationsMay be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
item.adjudication.modifierExtensionExtensions that cannot be ignored even if unrecognizedMay be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
item.adjudication.categoryType of adjudication informationA code to indicate the information type of this adjudication record. Information types may include the value submitted, maximum values or percentages allowed or payable under the plan, amounts that the patient is resonsible for in-aggregate or pertaining to this item, amounts paid by other coverages, and the benefit payable for this item.For example codes indicating: Co-Pay, deductible, eligible, benefit, tax, etc.
item.adjudication.reasonExplanation of adjudication outcomeA code supporting the understanding of the adjudication result and explaining variance from expected amount.For example may indicate that the funds for this benefit type have been exhausted.
item.adjudication.amountMonetary amountMonetary amount associated with the category.For example: amount submitted, eligible amount, co-payment, and benefit payable.
item.adjudication.valueNon-monetary valueA non-monetary value associated with the category. Mutually exclusive to the amount element above.For example: eligible percentage or co-payment percentage.
item.detailAdjudication for claim detailsA claim detail. Either a simple (a product or service) or a 'group' of sub-details which are simple items.
item.detail.idUnique id for inter-element referencingUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
item.detail.extensionAdditional content defined by implementationsMay be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
item.detail.modifierExtensionExtensions that cannot be ignored even if unrecognizedMay be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
item.detail.detailSequenceClaim detail instance identifierA number to uniquely reference the claim detail entry.
item.detail.noteNumberApplicable note numbersThe numbers associated with notes below which apply to the adjudication of this item.
item.detail.adjudicationDetail level adjudication detailsThe adjudication results.
item.detail.subDetailAdjudication for claim sub-detailsA sub-detail adjudication of a simple product or service.
item.detail.subDetail.idUnique id for inter-element referencingUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
item.detail.subDetail.extensionAdditional content defined by implementationsMay be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
item.detail.subDetail.modifierExtensionExtensions that cannot be ignored even if unrecognizedMay be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
item.detail.subDetail.subDetailSequenceClaim sub-detail instance identifierA number to uniquely reference the claim sub-detail entry.
item.detail.subDetail.noteNumberApplicable note numbersThe numbers associated with notes below which apply to the adjudication of this item.
item.detail.subDetail.adjudicationSubdetail level adjudication detailsThe adjudication results.
addItemInsurer added line itemsThe first-tier service adjudications for payor added product or service lines.
addItem.idUnique id for inter-element referencingUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
addItem.extensionAdditional content defined by implementationsMay be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
addItem.modifierExtensionExtensions that cannot be ignored even if unrecognizedMay be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
addItem.itemSequenceItem sequence numberClaim items which this service line is intended to replace.
addItem.detailSequenceDetail sequence numberThe sequence number of the details within the claim item which this line is intended to replace.
addItem.subdetailSequenceSubdetail sequence numberThe sequence number of the sub-details woithin the details within the claim item which this line is intended to replace.
addItem.providerAuthorized providersThe providers who are authorized for the services rendered to the patient.
addItem.productOrServiceBilling, service, product, or drug codeWhen the value is a group code then this item collects a set of related claim details, otherwise this contains the product, service, drug or other billing code for the item.If this is an actual service or product line, i.e. not a Group, then use code to indicate the Professional Service or Product supplied (e.g. CTP, HCPCS, USCLS, ICD10, NCPDP, DIN, RxNorm, ACHI, CCI). If a grouping item then use a group code to indicate the type of thing being grouped e.g. 'glasses' or 'compound'.
addItem.modifierService/Product billing modifiersItem typification or modifiers codes to convey additional context for the product or service.For example in Oral whether the treatment is cosmetic or associated with TMJ, or for Medical whether the treatment was outside the clinic or out of office hours.
addItem.programCodeProgram the product or service is provided underIdentifies the program under which this may be recovered.For example: Neonatal program, child dental program or drug users recovery program.
addItem.serviced[x]Date or dates of service or product deliveryThe date or dates when the service or product was supplied, performed or completed.
addItem.location[x]Place of service or where product was suppliedWhere the product or service was provided.
addItem.quantityCount of products or servicesThe number of repetitions of a service or product.
addItem.unitPriceFee, charge or cost per itemIf the item is not a group then this is the fee for the product or service, otherwise this is the total of the fees for the details of the group.
addItem.factorPrice scaling factorA real number that represents a multiplier used in determining the overall value of services delivered and/or goods received. The concept of a Factor allows for a discount or surcharge multiplier to be applied to a monetary amount.To show a 10% Senior's discount, the value entered is: 0.90 (1.00 - 0.10).
addItem.netTotal item costThe quantity times the unit price for an additional service or product or charge.For example, the formula: quantity * unitPrice * factor = net. Quantity and factor are assumed to be 1 if not supplied.
addItem.bodySiteAnatomical locationPhysical service site on the patient (limb, tooth, etc.).For example: Providing a tooth code, allows an insurer to identify a provider performing a filling on a tooth that was previously removed.
addItem.subSiteAnatomical sub-locationA region or surface of the bodySite, e.g. limb region or tooth surface(s).
addItem.noteNumberApplicable note numbersThe numbers associated with notes below which apply to the adjudication of this item.
addItem.adjudicationAdded items adjudicationThe adjudication results.
addItem.detailInsurer added line detailsThe second-tier service adjudications for payor added services.
addItem.detail.idUnique id for inter-element referencingUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
addItem.detail.extensionAdditional content defined by implementationsMay be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
addItem.detail.modifierExtensionExtensions that cannot be ignored even if unrecognizedMay be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
addItem.detail.productOrServiceBilling, service, product, or drug codeWhen the value is a group code then this item collects a set of related claim details, otherwise this contains the product, service, drug or other billing code for the item.If this is an actual service or product line, i.e. not a Group, then use code to indicate the Professional Service or Product supplied (e.g. CTP, HCPCS, USCLS, ICD10, NCPDP, DIN, RxNorm, ACHI, CCI). If a grouping item then use a group code to indicate the type of thing being grouped e.g. 'glasses' or 'compound'.
addItem.detail.modifierService/Product billing modifiersItem typification or modifiers codes to convey additional context for the product or service.For example in Oral whether the treatment is cosmetic or associated with TMJ, or for Medical whether the treatment was outside the clinic or out of office hours.
addItem.detail.quantityCount of products or servicesThe number of repetitions of a service or product.
addItem.detail.unitPriceFee, charge or cost per itemIf the item is not a group then this is the fee for the product or service, otherwise this is the total of the fees for the details of the group.
addItem.detail.factorPrice scaling factorA real number that represents a multiplier used in determining the overall value of services delivered and/or goods received. The concept of a Factor allows for a discount or surcharge multiplier to be applied to a monetary amount.To show a 10% Senior's discount, the value entered is: 0.90 (1.00 - 0.10).
addItem.detail.netTotal item costThe quantity times the unit price for an additional service or product or charge.For example, the formula: quantity * unitPrice * factor = net. Quantity and factor are assumed to be 1 if not supplied.
addItem.detail.noteNumberApplicable note numbersThe numbers associated with notes below which apply to the adjudication of this item.
addItem.detail.adjudicationAdded items detail adjudicationThe adjudication results.
addItem.detail.subDetailInsurer added line itemsThe third-tier service adjudications for payor added services.
addItem.detail.subDetail.idUnique id for inter-element referencingUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
addItem.detail.subDetail.extensionAdditional content defined by implementationsMay be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
addItem.detail.subDetail.modifierExtensionExtensions that cannot be ignored even if unrecognizedMay be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
addItem.detail.subDetail.productOrServiceBilling, service, product, or drug codeWhen the value is a group code then this item collects a set of related claim details, otherwise this contains the product, service, drug or other billing code for the item.If this is an actual service or product line, i.e. not a Group, then use code to indicate the Professional Service or Product supplied (e.g. CTP, HCPCS, USCLS, ICD10, NCPDP, DIN, RxNorm, ACHI, CCI). If a grouping item then use a group code to indicate the type of thing being grouped e.g. 'glasses' or 'compound'.
addItem.detail.subDetail.modifierService/Product billing modifiersItem typification or modifiers codes to convey additional context for the product or service.For example in Oral whether the treatment is cosmetic or associated with TMJ, or for Medical whether the treatment was outside the clinic or out of office hours.
addItem.detail.subDetail.quantityCount of products or servicesThe number of repetitions of a service or product.
addItem.detail.subDetail.unitPriceFee, charge or cost per itemIf the item is not a group then this is the fee for the product or service, otherwise this is the total of the fees for the details of the group.
addItem.detail.subDetail.factorPrice scaling factorA real number that represents a multiplier used in determining the overall value of services delivered and/or goods received. The concept of a Factor allows for a discount or surcharge multiplier to be applied to a monetary amount.To show a 10% Senior's discount, the value entered is: 0.90 (1.00 - 0.10).
addItem.detail.subDetail.netTotal item costThe quantity times the unit price for an additional service or product or charge.For example, the formula: quantity * unitPrice * factor = net. Quantity and factor are assumed to be 1 if not supplied.
addItem.detail.subDetail.noteNumberApplicable note numbersThe numbers associated with notes below which apply to the adjudication of this item.
addItem.detail.subDetail.adjudicationAdded items detail adjudicationThe adjudication results.
adjudicationHeader-level adjudicationThe adjudication results which are presented at the header level rather than at the line-item or add-item levels.
totalAdjudication totalsCategorized monetary totals for the adjudication.Totals for amounts submitted, co-pays, benefits payable etc.
total.idUnique id for inter-element referencingUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
total.extensionAdditional content defined by implementationsMay be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
total.modifierExtensionExtensions that cannot be ignored even if unrecognizedMay be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
total.categoryType of adjudication informationA code to indicate the information type of this adjudication record. Information types may include the value submitted, maximum values or percentages allowed or payable under the plan, amounts that the patient is resonsible for in-aggregate or pertaining to this item, amounts paid by other coverages, and the benefit payable for this item.For example codes indicating: Co-Pay, deductible, eligible, benefit, tax, etc.
total.amountFinancial total for the categoryMonetary total amount associated with the category.
paymentPayment DetailsPayment details for the adjudication of the claim.
payment.idUnique id for inter-element referencingUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
payment.extensionAdditional content defined by implementationsMay be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
payment.modifierExtensionExtensions that cannot be ignored even if unrecognizedMay be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
payment.typePartial or complete paymentWhether this represents partial or complete payment of the benefits payable.
payment.adjustmentPayment adjustment for non-claim issuesTotal amount of all adjustments to this payment included in this transaction which are not related to this claim's adjudication.Insurers will deduct amounts owing from the provider (adjustment), such as a prior overpayment, from the amount owing to the provider (benefits payable) when payment is made to the provider.
payment.adjustmentReasonExplanation for the adjustmentReason for the payment adjustment.
payment.dateExpected date of paymentEstimated date the payment will be issued or the actual issue date of payment.
payment.amountPayable amount after adjustmentBenefits payable less any payment adjustment.
payment.identifierBusiness identifier for the paymentIssuer's unique identifier for the payment instrument.For example: EFT number or check number.
fundsReserveFunds reserved statusA code, used only on a response to a preauthorization, to indicate whether the benefits payable have been reserved and for whom.Fund would be release by a future claim quoting the preAuthRef of this response. Examples of values include: provider, patient, none.
formCodePrinted form identifierA code for the form to be used for printing the content.May be needed to identify specific jurisdictional forms.
formPrinted reference or actual formThe actual form, by reference or inclusion, for printing the content or an EOB.Needed to permit insurers to include the actual form.
processNoteNote concerning adjudicationA note that describes or explains adjudication results in a human readable form.
processNote.idUnique id for inter-element referencingUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
processNote.extensionAdditional content defined by implementationsMay be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
processNote.modifierExtensionExtensions that cannot be ignored even if unrecognizedMay be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
processNote.numberNote instance identifierA number to uniquely identify a note entry.
processNote.typedisplay | print | printoperThe business purpose of the note text.
processNote.textNote explanatory textThe explanation or description associated with the processing.
processNote.languageLanguage of the textA code to define the language used in the text of the note.Only requred if the language is different from the resource language.
communicationRequestRequest for additional informationRequest for additional supporting or authorizing information.For example: professional reports, documents, images, clinical resources, or accident reports.
insurancePatient insurance informationFinancial instruments for reimbursement for the health care products and services specified on the claim.All insurance coverages for the patient which may be applicable for reimbursement, of the products and services listed in the claim, are typically provided in the claim to allow insurers to confirm the ordering of the insurance coverages relative to local 'coordination of benefit' rules. One coverage (and only one) with 'focal=true' is to be used in the adjudication of this claim. Coverages appearing before the focal Coverage in the list, and where 'subrogation=false', should provide a reference to the ClaimResponse containing the adjudication results of the prior claim.
insurance.idUnique id for inter-element referencingUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
insurance.extensionAdditional content defined by implementationsMay be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
insurance.modifierExtensionExtensions that cannot be ignored even if unrecognizedMay be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
insurance.sequenceInsurance instance identifierA number to uniquely identify insurance entries and provide a sequence of coverages to convey coordination of benefit order.
insurance.focalCoverage to be used for adjudicationA flag to indicate that this Coverage is to be used for adjudication of this claim when set to true.A patient may (will) have multiple insurance policies which provide reimburement for healthcare services and products. For example a person may also be covered by their spouse's policy and both appear in the list (and may be from the same insurer). This flag will be set to true for only one of the listed policies and that policy will be used for adjudicating this claim. Other claims woul dbe created to request adjudication against the other listed policies.
insurance.coverageInsurance informationReference to the insurance card level information contained in the Coverage resource. The coverage issuing insurer will use these details to locate the patient's actual coverage within the insurer's information system.
insurance.businessArrangementAdditional provider contract numberA business agreement number established between the provider and the insurer for special business processing purposes.
insurance.claimResponseAdjudication resultsThe result of the adjudication of the line items for the Coverage specified in this insurance.Must not be specified when 'focal=true' for this insurance.
errorProcessing errorsErrors encountered during the processing of the adjudication.If the request contains errors then an error element should be provided and no adjudication related sections (item, addItem, or payment) should be present.
error.idUnique id for inter-element referencingUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
error.extensionAdditional content defined by implementationsMay be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
error.modifierExtensionExtensions that cannot be ignored even if unrecognizedMay be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
error.itemSequenceItem sequence numberThe sequence number of the line item submitted which contains the error. This value is omitted when the error occurs outside of the item structure.
error.detailSequenceDetail sequence numberThe sequence number of the detail within the line item submitted which contains the error. This value is omitted when the error occurs outside of the item structure.
error.subDetailSequenceSubdetail sequence numberThe sequence number of the sub-detail within the detail within the line item submitted which contains the error. This value is omitted when the error occurs outside of the item structure.
error.codeError code detailing processing issuesAn error code, from a specified code system, which details why the claim could not be adjudicated.

Scope and Usage

The ClaimResponse resource provides application level adjudication results, or an application level error, which are the result of processing a submitted Claim resource where that Claim may be the functional corollary of a Claim, Predetermination or a Preauthorization.This resource is the only appropriate response to a Claim which a processing system recognizes as a Claim resource.

This is the adjudicated response to a Claim, Predetermination or PreAuthorization. The strength of the payment aspect of the response is matching to the strength of the original request. For a Claim the adjudication indicates payment which is intended to be made. For Preauthorization no payment will actually be made however funds may be reserved to settle a claim submitted later. For Preaetermination no payment will actually be made and no assurance is given that the adjudication of a claim submitted later will match the adjudication provided, for example funds may have been exhausted in the interim. Only an actual claim may be expected to result in actual payment.

The ClaimResponse resource may also be returned with the response for the submission of: Re-adjudication and Reversals.

The ClaimResponse resource is an "event" resource from a FHIR workflow perspective - see Workflow Event.

Additional Information

Additional information regarding electronic claims content and usage may be found at:

Boundaries and Relationships

The ClaimResponse resource is used to provide the results of the adjudication and/or authorization of a set of healthcare-related products and services for a patient against the patient's insurance coverages, or to respond with what the adjudication would be for a supplied set of products or services should they be actually supplied to the patient.

The ExplanationOfBenefit resource is for reporting out to patients or transferring data to patient centered applications, such as patient health Record (PHR) application, the ExplanationOfBenefit should be used instead of the Claim and ClaimResponse resources as those resources may contain provider and payer specific information which is not appropriate for sharing with the patient.

When using the resources for reporting and transferring claims data, which may have originated in some standard other than FHIR, the Claim resource is useful if only the request side of the information exchange is of interest. If, however, both the request and the adjudication information is to be reported then the ExplanationOfBenefit should be used instead.

When responding whether the patient's coverage is inforce, whether it is valid at this or a specified date, or returning the benefit details or preauthorization requirements associated with a coverage CoverageEligibilityResponse should be used instead and be the response to a CoverageEligibilityRequest.

The eClaim domain includes a number of related resources
ClaimResponse A payor's adjudication and/or authorization response to the suite of services provided in a Claim. Typically the ClaimResponse references the Claim but does not duplicate the clinical or financial information provided in the claim.
ExplanationOfBenefit This resource combines the information from the Claim and the ClaimResponse, stripping out any provider or payor proprietary information, into a unified information model suitable for use for: patient reporting; transferring information to a Patient Health Record system; and, supporting complete claim and adjudication information exchange with regulatory and analytics organizations and other parts of the provider's organization.
Claim A suite of goods and services and insurances coverages under which adjudication or authorization is requested.
CoverageEligibilityResponse The response to a request to a payor, a CoverageEligibilityRequest, to: ascertain whether a coverage is in-force at the current or at a specified time; list the table of benefits; determine whether coverage is provided for specified categories or specific services; and whether preauthorization is required, and if so what supporting information would be required.


Search Parameters

createdThe creation dateClaimResponse.created
dispositionThe contents of the disposition messageClaimResponse.disposition
identifierThe identity of the ClaimResponseClaimResponse.identifier
insurerThe organization who generated this resourceClaimResponse.insurer
outcomeThe processing outcomeClaimResponse.outcome
patientThe subject of careClaimResponse.patient
payment-dateThe expected payment dateClaimResponse.payment.date
requestThe claim referenceClaimResponse.request
requestorThe Provider of the claimClaimResponse.requestor
statusThe status of the ClaimResponseClaimResponse.status
useThe type of claimClaimResponse.use

Extension Definitions

These are extension definitions for this resource defined by the spec