Name | Flags | Card. | Type | Description & Constraints![]() |
---|---|---|---|---|
TU | DomainResource | Response to a claim predetermination or preauthorization Elements defined in Ancestors: id, meta, implicitRules, language, text, contained, extension, modifierExtension | ||
0..* | Identifier | Business Identifier for a claim response | ||
?!Σ | 1..1 | code | active | cancelled | draft | entered-in-error Financial Resource Status Codes (Required) | |
Σ | 1..1 | CodeableConcept | More granular claim type Claim Type Codes (Extensible) | |
0..1 | CodeableConcept | More granular claim type Example Claim SubType Codes (Example) | ||
Σ | 1..1 | code | claim | preauthorization | predetermination Use (Required) | |
Σ | 1..1 | Reference(Patient) | The recipient of the products and services | |
Σ | 1..1 | dateTime | Response creation date | |
Σ | 1..1 | Reference(Organization) | Party responsible for reimbursement | |
0..1 | Reference(Practitioner | PractitionerRole | Organization) | Party responsible for the claim | ||
Σ | 0..1 | Reference(Claim) | Id of resource triggering adjudication | |
Σ | 1..1 | code | queued | complete | error | partial Claim Processing Codes (Required) | |
0..1 | string | Disposition Message | ||
0..1 | string | Preauthorization reference | ||
0..1 | Period | Preauthorization reference effective period | ||
0..1 | CodeableConcept | Party to be paid any benefits payable PayeeType (Example) | ||
0..* | BackboneElement | Adjudication for claim line items | ||
1..1 | positiveInt | Claim item instance identifier | ||
0..* | positiveInt | Applicable note numbers | ||
1..* | BackboneElement | Adjudication details | ||
1..1 | CodeableConcept | Type of adjudication information Adjudication Value Codes (Example) | ||
0..1 | CodeableConcept | Explanation of adjudication outcome Adjudication Reason Codes (Example) | ||
0..1 | Money | Monetary amount | ||
0..1 | decimal | Non-monetary value | ||
0..* | BackboneElement | Adjudication for claim details | ||
1..1 | positiveInt | Claim detail instance identifier | ||
0..* | positiveInt | Applicable note numbers | ||
1..* | see adjudication | Detail level adjudication details | ||
0..* | BackboneElement | Adjudication for claim sub-details | ||
1..1 | positiveInt | Claim sub-detail instance identifier | ||
0..* | positiveInt | Applicable note numbers | ||
0..* | see adjudication | Subdetail level adjudication details | ||
0..* | BackboneElement | Insurer added line items | ||
0..* | positiveInt | Item sequence number | ||
0..* | positiveInt | Detail sequence number | ||
0..* | positiveInt | Subdetail sequence number | ||
0..* | Reference(Practitioner | PractitionerRole | Organization) | Authorized providers | ||
1..1 | CodeableConcept | Billing, service, product, or drug code USCLS Codes (Example) | ||
0..* | CodeableConcept | Service/Product billing modifiers Modifier type Codes (Example) | ||
0..* | CodeableConcept | Program the product or service is provided under Example Program Reason Codes (Example) | ||
0..1 | Date or dates of service or product delivery | |||
date | ||||
Period | ||||
0..1 | Place of service or where product was supplied Example Service Place Codes (Example) | |||
CodeableConcept | ||||
Address | ||||
Reference(Location) | ||||
0..1 | SimpleQuantity | Count of products or services | ||
0..1 | Money | Fee, charge or cost per item | ||
0..1 | decimal | Price scaling factor | ||
0..1 | Money | Total item cost | ||
0..1 | CodeableConcept | Anatomical location Oral Site Codes (Example) | ||
0..* | CodeableConcept | Anatomical sub-location Surface Codes (Example) | ||
0..* | positiveInt | Applicable note numbers | ||
1..* | see adjudication | Added items adjudication | ||
0..* | BackboneElement | Insurer added line details | ||
1..1 | CodeableConcept | Billing, service, product, or drug code USCLS Codes (Example) | ||
0..* | CodeableConcept | Service/Product billing modifiers Modifier type Codes (Example) | ||
0..1 | SimpleQuantity | Count of products or services | ||
0..1 | Money | Fee, charge or cost per item | ||
0..1 | decimal | Price scaling factor | ||
0..1 | Money | Total item cost | ||
0..* | positiveInt | Applicable note numbers | ||
1..* | see adjudication | Added items detail adjudication | ||
0..* | BackboneElement | Insurer added line items | ||
1..1 | CodeableConcept | Billing, service, product, or drug code USCLS Codes (Example) | ||
0..* | CodeableConcept | Service/Product billing modifiers Modifier type Codes (Example) | ||
0..1 | SimpleQuantity | Count of products or services | ||
0..1 | Money | Fee, charge or cost per item | ||
0..1 | decimal | Price scaling factor | ||
0..1 | Money | Total item cost | ||
0..* | positiveInt | Applicable note numbers | ||
1..* | see adjudication | Added items detail adjudication | ||
0..* | see adjudication | Header-level adjudication | ||
Σ | 0..* | BackboneElement | Adjudication totals | |
Σ | 1..1 | CodeableConcept | Type of adjudication information Adjudication Value Codes (Example) | |
Σ | 1..1 | Money | Financial total for the category | |
0..1 | BackboneElement | Payment Details | ||
1..1 | CodeableConcept | Partial or complete payment Example Payment Type Codes (Example) | ||
0..1 | Money | Payment adjustment for non-claim issues | ||
0..1 | CodeableConcept | Explanation for the adjustment Payment Adjustment Reason Codes (Example) | ||
0..1 | date | Expected date of payment | ||
1..1 | Money | Payable amount after adjustment | ||
0..1 | Identifier | Business identifier for the payment | ||
0..1 | CodeableConcept | Funds reserved status FundsReserve (Example) | ||
0..1 | CodeableConcept | Printed form identifier Forms (Example) | ||
0..1 | Attachment | Printed reference or actual form | ||
0..* | BackboneElement | Note concerning adjudication | ||
0..1 | positiveInt | Note instance identifier | ||
0..1 | code | display | print | printoper NoteType (Required) | ||
1..1 | string | Note explanatory text | ||
0..1 | CodeableConcept | Language of the text Common Languages (Preferred but limited to AllLanguages) | ||
0..* | Reference(CommunicationRequest) | Request for additional information | ||
0..* | BackboneElement | Patient insurance information | ||
1..1 | positiveInt | Insurance instance identifier | ||
1..1 | boolean | Coverage to be used for adjudication | ||
1..1 | Reference(Coverage) | Insurance information | ||
0..1 | string | Additional provider contract number | ||
0..1 | Reference(ClaimResponse) | Adjudication results | ||
0..* | BackboneElement | Processing errors | ||
0..1 | positiveInt | Item sequence number | ||
0..1 | positiveInt | Detail sequence number | ||
0..1 | positiveInt | Subdetail sequence number | ||
1..1 | CodeableConcept | Error code detailing processing issues AdjudicationError (Example) | ||
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