NameFlagsCard.TypeDescription & Constraintsdoco
.. ClaimResponse TUDomainResourceResponse to a claim predetermination or preauthorization
Elements defined in Ancestors: id, meta, implicitRules, language, text, contained, extension, modifierExtension
... identifier 0..*IdentifierBusiness Identifier for a claim response
... status ?!Σ1..1codeactive | cancelled | draft | entered-in-error
Financial Resource Status Codes (Required)
... type Σ1..1CodeableConceptMore granular claim type
Claim Type Codes (Extensible)
... subType 0..1CodeableConceptMore granular claim type
Example Claim SubType Codes (Example)
... use Σ1..1codeclaim | preauthorization | predetermination
Use (Required)
... patient Σ1..1Reference(Patient)The recipient of the products and services
... created Σ1..1dateTimeResponse creation date
... insurer Σ1..1Reference(Organization)Party responsible for reimbursement
... requestor 0..1Reference(Practitioner | PractitionerRole | Organization)Party responsible for the claim
... request Σ0..1Reference(Claim)Id of resource triggering adjudication
... outcome Σ1..1codequeued | complete | error | partial
Claim Processing Codes (Required)
... disposition 0..1stringDisposition Message
... preAuthRef 0..1stringPreauthorization reference
... preAuthPeriod 0..1PeriodPreauthorization reference effective period
... payeeType 0..1CodeableConceptParty to be paid any benefits payable
PayeeType (Example)
... item 0..*BackboneElementAdjudication for claim line items
.... itemSequence 1..1positiveIntClaim item instance identifier
.... noteNumber 0..*positiveIntApplicable note numbers
.... adjudication 1..*BackboneElementAdjudication details
..... category 1..1CodeableConceptType of adjudication information
Adjudication Value Codes (Example)
..... reason 0..1CodeableConceptExplanation of adjudication outcome
Adjudication Reason Codes (Example)
..... amount 0..1MoneyMonetary amount
..... value 0..1decimalNon-monetary value
.... detail 0..*BackboneElementAdjudication for claim details
..... detailSequence 1..1positiveIntClaim detail instance identifier
..... noteNumber 0..*positiveIntApplicable note numbers
..... adjudication 1..*see adjudicationDetail level adjudication details
..... subDetail 0..*BackboneElementAdjudication for claim sub-details
...... subDetailSequence 1..1positiveIntClaim sub-detail instance identifier
...... noteNumber 0..*positiveIntApplicable note numbers
...... adjudication 0..*see adjudicationSubdetail level adjudication details
... addItem 0..*BackboneElementInsurer added line items
.... itemSequence 0..*positiveIntItem sequence number
.... detailSequence 0..*positiveIntDetail sequence number
.... subdetailSequence 0..*positiveIntSubdetail sequence number
.... provider 0..*Reference(Practitioner | PractitionerRole | Organization)Authorized providers
.... productOrService 1..1CodeableConceptBilling, service, product, or drug code
USCLS Codes (Example)
.... modifier 0..*CodeableConceptService/Product billing modifiers
Modifier type Codes (Example)
.... programCode 0..*CodeableConceptProgram the product or service is provided under
Example Program Reason Codes (Example)
.... serviced[x] 0..1Date or dates of service or product delivery
..... servicedDatedate
..... servicedPeriodPeriod
.... location[x] 0..1Place of service or where product was supplied
Example Service Place Codes (Example)
..... locationCodeableConceptCodeableConcept
..... locationAddressAddress
..... locationReferenceReference(Location)
.... quantity 0..1SimpleQuantityCount of products or services
.... unitPrice 0..1MoneyFee, charge or cost per item
.... factor 0..1decimalPrice scaling factor
.... net 0..1MoneyTotal item cost
.... bodySite 0..1CodeableConceptAnatomical location
Oral Site Codes (Example)
.... subSite 0..*CodeableConceptAnatomical sub-location
Surface Codes (Example)
.... noteNumber 0..*positiveIntApplicable note numbers
.... adjudication 1..*see adjudicationAdded items adjudication
.... detail 0..*BackboneElementInsurer added line details
..... productOrService 1..1CodeableConceptBilling, service, product, or drug code
USCLS Codes (Example)
..... modifier 0..*CodeableConceptService/Product billing modifiers
Modifier type Codes (Example)
..... quantity 0..1SimpleQuantityCount of products or services
..... unitPrice 0..1MoneyFee, charge or cost per item
..... factor 0..1decimalPrice scaling factor
..... net 0..1MoneyTotal item cost
..... noteNumber 0..*positiveIntApplicable note numbers
..... adjudication 1..*see adjudicationAdded items detail adjudication
..... subDetail 0..*BackboneElementInsurer added line items
...... productOrService 1..1CodeableConceptBilling, service, product, or drug code
USCLS Codes (Example)
...... modifier 0..*CodeableConceptService/Product billing modifiers
Modifier type Codes (Example)
...... quantity 0..1SimpleQuantityCount of products or services
...... unitPrice 0..1MoneyFee, charge or cost per item
...... factor 0..1decimalPrice scaling factor
...... net 0..1MoneyTotal item cost
...... noteNumber 0..*positiveIntApplicable note numbers
...... adjudication 1..*see adjudicationAdded items detail adjudication
... adjudication 0..*see adjudicationHeader-level adjudication
... total Σ0..*BackboneElementAdjudication totals
.... category Σ1..1CodeableConceptType of adjudication information
Adjudication Value Codes (Example)
.... amount Σ1..1MoneyFinancial total for the category
... payment 0..1BackboneElementPayment Details
.... type 1..1CodeableConceptPartial or complete payment
Example Payment Type Codes (Example)
.... adjustment 0..1MoneyPayment adjustment for non-claim issues
.... adjustmentReason 0..1CodeableConceptExplanation for the adjustment
Payment Adjustment Reason Codes (Example)
.... date 0..1dateExpected date of payment
.... amount 1..1MoneyPayable amount after adjustment
.... identifier 0..1IdentifierBusiness identifier for the payment
... fundsReserve 0..1CodeableConceptFunds reserved status
FundsReserve (Example)
... formCode 0..1CodeableConceptPrinted form identifier
Forms (Example)
... form 0..1AttachmentPrinted reference or actual form
... processNote 0..*BackboneElementNote concerning adjudication
.... number 0..1positiveIntNote instance identifier
.... type 0..1codedisplay | print | printoper
NoteType (Required)
.... text 1..1stringNote explanatory text
.... language 0..1CodeableConceptLanguage of the text
Common Languages (Preferred but limited to AllLanguages)
... communicationRequest 0..*Reference(CommunicationRequest)Request for additional information
... insurance 0..*BackboneElementPatient insurance information
.... sequence 1..1positiveIntInsurance instance identifier
.... focal 1..1booleanCoverage to be used for adjudication
.... coverage 1..1Reference(Coverage)Insurance information
.... businessArrangement 0..1stringAdditional provider contract number
.... claimResponse 0..1Reference(ClaimResponse)Adjudication results
... error 0..*BackboneElementProcessing errors
.... itemSequence 0..1positiveIntItem sequence number
.... detailSequence 0..1positiveIntDetail sequence number
.... subDetailSequence 0..1positiveIntSubdetail sequence number
.... code 1..1CodeableConceptError code detailing processing issues
AdjudicationError (Example)

doco Documentation for this format