NameFlagsCard.TypeDescription & Constraintsdoco
.. ClaimResponse DomainResourceRemittance resource
... identifier 0..*IdentifierResponse number
... status ?!Σ1..1codeactive | cancelled | draft | entered-in-error
ClaimResponseStatus (Required)
... request[x] 0..1Id of resource triggering adjudication
.... requestIdentifierIdentifier
.... requestReferenceReference(Claim)
... ruleset 0..1CodingResource version
Ruleset Codes (Example)
... originalRuleset 0..1CodingOriginal version
Ruleset Codes (Example)
... created 0..1dateTimeCreation date
... organization[x] 0..1Insurer
.... organizationIdentifierIdentifier
.... organizationReferenceReference(Organization)
... requestProvider[x] 0..1Responsible practitioner
.... requestProviderIdentifierIdentifier
.... requestProviderReferenceReference(Practitioner)
... requestOrganization[x] 0..1Responsible organization
.... requestOrganizationIdentifierIdentifier
.... requestOrganizationReferenceReference(Organization)
... outcome 0..1Codingcomplete | error | partial
Claim Processing Codes (Example)
... disposition 0..1stringDisposition Message
... payeeType 0..1CodingParty to be paid any benefits payable
Payee Type Codes (Example)
... item 0..*BackboneElementLine items
.... sequenceLinkId 1..1positiveIntService instance
.... noteNumber 0..*positiveIntList of note numbers which apply
.... adjudication 0..*BackboneElementAdjudication details
..... category 1..1CodingAdjudication category such as co-pay, eligible, benefit, etc.
Adjudication Codes (Extensible)
..... reason 0..1CodingAdjudication reason
Adjudication Reason Codes (Extensible)
..... amount 0..1MoneyMonetary amount
..... value 0..1decimalNon-monetary value
.... detail 0..*BackboneElementDetail line items
..... sequenceLinkId 1..1positiveIntService instance
..... noteNumber 0..*positiveIntList of note numbers which apply
..... adjudication 0..*see adjudicationDetail adjudication
..... subDetail 0..*BackboneElementSubdetail line items
...... sequenceLinkId 1..1positiveIntService instance
...... noteNumber 0..*positiveIntList of note numbers which apply
...... adjudication 0..*see adjudicationSubdetail adjudication
... addItem 0..*BackboneElementInsurer added line items
.... sequenceLinkId 0..*positiveIntService instances
.... revenue 0..1CodingRevenue or cost center code
Example Revenue Center Codes (Example)
.... category 0..1CodingType of service or product
Benefit SubCategory Codes (Example)
.... service 0..1CodingGroup, Service or Product
USCLS Codes (Example)
.... modifier 0..*CodingService/Product billing modifiers
Modifier type Codes (Example)
.... fee 0..1MoneyProfessional fee or Product charge
.... noteNumber 0..*positiveIntList of note numbers which apply
.... adjudication 0..*see adjudicationAdded items adjudication
.... detail 0..*BackboneElementAdded items details
..... revenue 0..1CodingRevenue or cost center code
Example Revenue Center Codes (Example)
..... category 0..1CodingType of service or product
Benefit SubCategory Codes (Example)
..... service 0..1CodingService or Product
USCLS Codes (Example)
..... modifier 0..*CodingService/Product billing modifiers
Modifier type Codes (Example)
..... fee 0..1MoneyProfessional fee or Product charge
..... noteNumber 0..*positiveIntList of note numbers which apply
..... adjudication 0..*see adjudicationAdded items detail adjudication
... error 0..*BackboneElementProcessing errors
.... sequenceLinkId 0..1positiveIntItem sequence number
.... detailSequenceLinkId 0..1positiveIntDetail sequence number
.... subdetailSequenceLinkId 0..1positiveIntSubdetail sequence number
.... code 1..1CodingError code detailing processing issues
Adjudication Error Codes (Extensible)
... totalCost 0..1MoneyTotal Cost of service from the Claim
... unallocDeductable 0..1MoneyUnallocated deductible
... totalBenefit 0..1MoneyTotal benefit payable for the Claim
... payment 0..1BackboneElement
.... type 0..1CodingPartial or Complete
Example Payment Type Codes (Example)
.... adjustment 0..1MoneyPayment adjustment for non-Claim issues
.... adjustmentReason 0..1CodingReason for Payment adjustment
Payment Adjustment Reason Codes (Extensible)
.... date 0..1dateExpected data of Payment
.... amount 0..1MoneyPayment amount
.... identifier 0..1IdentifierPayment identifier
... reserved 0..1CodingFunds reserved status
Funds Reservation Codes (Example)
... form 0..1CodingPrinted Form Identifier
Form Codes (Required)
... note 0..*BackboneElementProcessing notes
.... number 0..1positiveIntNote Number for this note
.... type 0..1Codingdisplay | print | printoper
NoteType (Required)
.... text 0..1stringNote explanatory text
.... language 0..1CodingLanguage
Common Languages (Extensible but limited to All Languages)
... coverage 0..*BackboneElementInsurance or medical plan
.... sequence 1..1positiveIntService instance identifier
.... focal 1..1booleanIs the focal Coverage
.... coverage[x] 1..1Insurance information
..... coverageIdentifierIdentifier
..... coverageReferenceReference(Coverage)
.... businessArrangement 0..1stringBusiness agreement
.... preAuthRef 0..*stringPre-Authorization/Determination Reference
.... claimResponse 0..1Reference(ClaimResponse)Adjudication results

doco Documentation for this format