| Name | Flags | Card. | Type | Description & Constraints![]() |
|---|---|---|---|---|
| Σ | DomainResource | Remittance resource | ||
| Σ | 0..* | Identifier | Response number | |
| Σ | 0..1 | Reference(Claim) | Id of resource triggering adjudication | |
| Σ | 0..1 | Coding | Resource version Ruleset Codes (Example) | |
| Σ | 0..1 | Coding | Original version Ruleset Codes (Example) | |
| Σ | 0..1 | dateTime | Creation date | |
| Σ | 0..1 | Reference(Organization) | Insurer | |
| Σ | 0..1 | Reference(Practitioner) | Responsible practitioner | |
| Σ | 0..1 | Reference(Organization) | Responsible organization | |
| Σ | 0..1 | code | complete | error RemittanceOutcome (Required) | |
| Σ | 0..1 | string | Disposition Message | |
| Σ | 0..1 | Coding | Party to be paid any benefits payable Payee type Codes (Example) | |
| Σ | 0..* | BackboneElement | Line items | |
| Σ | 1..1 | positiveInt | Service instance | |
| Σ | 0..* | positiveInt | List of note numbers which apply | |
| Σ | 0..* | BackboneElement | Adjudication details | |
| Σ | 1..1 | Coding | Adjudication category such as co-pay, eligible, benefit, etc. Adjudication Codes (Extensible) | |
| Σ | 0..1 | Money | Monetary amount | |
| Σ | 0..1 | decimal | Non-monitory value | |
| Σ | 0..* | BackboneElement | Detail line items | |
| Σ | 1..1 | positiveInt | Service instance | |
| Σ | 0..* | BackboneElement | Detail adjudication | |
| Σ | 1..1 | Coding | Adjudication category such as co-pay, eligible, benefit, etc. Adjudication Codes (Extensible) | |
| Σ | 0..1 | Money | Monetary amount | |
| Σ | 0..1 | decimal | Non-monitory value | |
| Σ | 0..* | BackboneElement | Subdetail line items | |
| Σ | 1..1 | positiveInt | Service instance | |
| Σ | 0..* | BackboneElement | Subdetail adjudication | |
| Σ | 1..1 | Coding | Adjudication category such as co-pay, eligible, benefit, etc. Adjudication Codes (Extensible) | |
| Σ | 0..1 | Money | Monetary amount | |
| Σ | 0..1 | decimal | Non-monitory value | |
| Σ | 0..* | BackboneElement | Insurer added line items | |
| Σ | 0..* | positiveInt | Service instances | |
| Σ | 1..1 | Coding | Group, Service or Product USCLS Codes (Example) | |
| Σ | 0..1 | Money | Professional fee or Product charge | |
| Σ | 0..* | positiveInt | List of note numbers which apply | |
| Σ | 0..* | BackboneElement | Added items adjudication | |
| Σ | 1..1 | Coding | Adjudication category such as co-pay, eligible, benefit, etc. Adjudication Codes (Extensible) | |
| Σ | 0..1 | Money | Monetary amount | |
| Σ | 0..1 | decimal | Non-monitory value | |
| Σ | 0..* | BackboneElement | Added items details | |
| Σ | 1..1 | Coding | Service or Product USCLS Codes (Example) | |
| Σ | 0..1 | Money | Professional fee or Product charge | |
| Σ | 0..* | BackboneElement | Added items detail adjudication | |
| Σ | 1..1 | Coding | Adjudication category such as co-pay, eligible, benefit, etc. Adjudication Codes (Extensible) | |
| Σ | 0..1 | Money | Monetary amount | |
| Σ | 0..1 | decimal | Non-monitory value | |
| Σ | 0..* | BackboneElement | Processing errors | |
| Σ | 0..1 | positiveInt | Item sequence number | |
| Σ | 0..1 | positiveInt | Detail sequence number | |
| Σ | 0..1 | positiveInt | Subdetail sequence number | |
| Σ | 1..1 | Coding | Error code detailing processing issues Adjudication Error Codes (Required) | |
| Σ | 0..1 | Money | Total Cost of service from the Claim | |
| Σ | 0..1 | Money | Unallocated deductable | |
| Σ | 0..1 | Money | Total benefit payable for the Claim | |
| Σ | 0..1 | Money | Payment adjustment for non-Claim issues | |
| Σ | 0..1 | Coding | Reason for Payment adjustment Adjustment Reason Codes (Extensible) | |
| Σ | 0..1 | date | Expected data of Payment | |
| Σ | 0..1 | Money | Payment amount | |
| Σ | 0..1 | Identifier | Payment identifier | |
| Σ | 0..1 | Coding | Funds reserved status Funds Reservation Codes (Example) | |
| Σ | 0..1 | Coding | Printed Form Identifier Form Codes (Required) | |
| Σ | 0..* | BackboneElement | Processing notes | |
| Σ | 0..1 | positiveInt | Note Number for this note | |
| Σ | 0..1 | Coding | display | print | printoper NoteType (Required) | |
| Σ | 0..1 | string | Note explanitory text | |
| Σ | 0..* | BackboneElement | Insurance or medical plan | |
| Σ | 1..1 | positiveInt | Service instance identifier | |
| Σ | 1..1 | boolean | Is the focal Coverage | |
| Σ | 1..1 | Reference(Coverage) | Insurance information | |
| Σ | 0..1 | string | Business agreement | |
| Σ | 1..1 | Coding | Patient relationship to subscriber Surface Codes (Example) | |
| Σ | 0..* | string | Pre-Authorization/Determination Reference | |
| Σ | 0..1 | Reference(ClaimResponse) | Adjudication results | |
| Σ | 0..1 | Coding | Original version Ruleset Codes (Example) | |
Documentation for this format | ||||