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