NameFlagsCard.TypeDescription & Constraintsdoco
.. ClaimResponse ΣDomainResourceRemittance resource
... identifier Σ0..*IdentifierResponse number
... request Σ0..1Reference(Claim)Id of resource triggering adjudication
... ruleset Σ0..1CodingResource version
Ruleset Codes (Example)
... originalRuleset Σ0..1CodingOriginal version
Ruleset Codes (Example)
... created Σ0..1dateTimeCreation date
... organization Σ0..1Reference(Organization)Insurer
... requestProvider Σ0..1Reference(Practitioner)Responsible practitioner
... requestOrganization Σ0..1Reference(Organization)Responsible organization
... outcome Σ0..1codecomplete | error
RemittanceOutcome (Required)
... disposition Σ0..1stringDisposition Message
... payeeType Σ0..1CodingParty to be paid any benefits payable
Payee Type Codes (Example)
... item Σ0..*BackboneElementLine items
.... sequenceLinkId Σ1..1positiveIntService instance
.... noteNumber Σ0..*positiveIntList of note numbers which apply
.... adjudication Σ0..*BackboneElementAdjudication details
..... code Σ1..1CodingAdjudication category such as co-pay, eligible, benefit, etc.
Adjudication Codes (Extensible)
..... amount Σ0..1MoneyMonetary amount
..... value Σ0..1decimalNon-monetary value
.... detail Σ0..*BackboneElementDetail line items
..... sequenceLinkId Σ1..1positiveIntService instance
..... adjudication Σ0..*BackboneElementDetail adjudication
...... code Σ1..1CodingAdjudication category such as co-pay, eligible, benefit, etc.
Adjudication Codes (Extensible)
...... amount Σ0..1MoneyMonetary amount
...... value Σ0..1decimalNon-monetary value
..... subDetail Σ0..*BackboneElementSubdetail line items
...... sequenceLinkId Σ1..1positiveIntService instance
...... adjudication Σ0..*BackboneElementSubdetail adjudication
....... code Σ1..1CodingAdjudication category such as co-pay, eligible, benefit, etc.
Adjudication Codes (Extensible)
....... amount Σ0..1MoneyMonetary amount
....... value Σ0..1decimalNon-monetary value
... addItem Σ0..*BackboneElementInsurer added line items
.... sequenceLinkId Σ0..*positiveIntService instances
.... service Σ1..1CodingGroup, Service or Product
USCLS Codes (Example)
.... fee Σ0..1MoneyProfessional fee or Product charge
.... noteNumberLinkId Σ0..*positiveIntList of note numbers which apply
.... adjudication Σ0..*BackboneElementAdded items adjudication
..... code Σ1..1CodingAdjudication category such as co-pay, eligible, benefit, etc.
Adjudication Codes (Extensible)
..... amount Σ0..1MoneyMonetary amount
..... value Σ0..1decimalNon-monetary value
.... detail Σ0..*BackboneElementAdded items details
..... service Σ1..1CodingService or Product
USCLS Codes (Example)
..... fee Σ0..1MoneyProfessional fee or Product charge
..... adjudication Σ0..*BackboneElementAdded items detail adjudication
...... code Σ1..1CodingAdjudication category such as co-pay, eligible, benefit, etc.
Adjudication Codes (Extensible)
...... amount Σ0..1MoneyMonetary amount
...... value Σ0..1decimalNon-monetary value
... error Σ0..*BackboneElementProcessing errors
.... sequenceLinkId Σ0..1positiveIntItem sequence number
.... detailSequenceLinkId Σ0..1positiveIntDetail sequence number
.... subdetailSequenceLinkId Σ0..1positiveIntSubdetail sequence number
.... code Σ1..1CodingError code detailing processing issues
Adjudication Error Codes (Extensible)
... totalCost Σ0..1MoneyTotal Cost of service from the Claim
... unallocDeductable Σ0..1MoneyUnallocated deductible
... totalBenefit Σ0..1MoneyTotal benefit payable for the Claim
... paymentAdjustment Σ0..1MoneyPayment adjustment for non-Claim issues
... paymentAdjustmentReason Σ0..1CodingReason for Payment adjustment
Payment Adjustment Reason Codes (Extensible)
... paymentDate Σ0..1dateExpected data of Payment
... paymentAmount Σ0..1MoneyPayment amount
... paymentRef Σ0..1IdentifierPayment identifier
... reserved Σ0..1CodingFunds reserved status
Funds Reservation Codes (Example)
... form Σ0..1CodingPrinted Form Identifier
Form Codes (Required)
... note Σ0..*BackboneElementProcessing notes
.... number Σ0..1positiveIntNote Number for this note
.... type Σ0..1Codingdisplay | print | printoper
NoteType (Required)
.... text Σ0..1stringNote explanatory text
... coverage Σ0..*BackboneElementInsurance or medical plan
.... sequence Σ1..1positiveIntService instance identifier
.... focal Σ1..1booleanIs the focal Coverage
.... coverage Σ1..1Reference(Coverage)Insurance information
.... businessArrangement Σ0..1stringBusiness agreement
.... relationship Σ1..1CodingPatient relationship to subscriber
Surface Codes (Example)
.... preAuthRef Σ0..*stringPre-Authorization/Determination Reference
.... claimResponse Σ0..1Reference(ClaimResponse)Adjudication results
.... originalRuleset Σ0..1CodingOriginal version
Ruleset Codes (Example)

doco Documentation for this format