ClaimResponse

ResourceFinancial · BillingTrial useMaturity 2

This resource provides the adjudication details from the processing of a Claim resource.

StructureSearch parametersHL7 specificationStructureDefinition JSON

Tested supportFull test results →

Backends

PostgreSQLElasticsearch

Interactions

CreateReadUpdatePatchDelete

Search

11 of 11 parameters tested

Structure

Show inherited elements (44)

Element	Card.	Type	Description
identifier	0..*	Identifier	Business Identifier for a claim response
statusRequired?!Σ	1..1	code	active | cancelled | draft | entered-in-errorBinding (required): fm-status
typeRequiredΣ	1..1	CodeableConcept	More granular claim typeBinding (extensible): claim-type
subType	0..1	CodeableConcept	More granular claim typeBinding (example): claim-subtype
useRequiredΣ	1..1	code	claim | preauthorization | predeterminationBinding (required): claim-use
patientRequiredΣ	1..1	Reference(Patient)	The recipient of the products and services
createdRequiredΣ	1..1	dateTime	Response creation date
insurerRequiredΣ	1..1	Reference(Organization)	Party responsible for reimbursement
requestor	0..1	Reference(Practitioner | PractitionerRole | Organization)	Party responsible for the claim
requestΣ	0..1	Reference(Claim)	Id of resource triggering adjudication
outcomeRequiredΣ	1..1	code	queued | complete | error | partialBinding (required): remittance-outcome
disposition	0..1	string	Disposition Message
preAuthRef	0..1	string	Preauthorization reference
preAuthPeriod	0..1	Period	Preauthorization reference effective period
payeeType	0..1	CodeableConcept	Party to be paid any benefits payableBinding (example): payeetype
item	0..*	BackboneElement	Adjudication for claim line items
itemSequenceRequired	1..1	positiveInt	Claim item instance identifier
noteNumber	0..*	positiveInt	Applicable note numbers
adjudicationRequired	1..*	BackboneElement	Adjudication details
categoryRequired	1..1	CodeableConcept	Type of adjudication informationBinding (example): adjudication
reason	0..1	CodeableConcept	Explanation of adjudication outcomeBinding (example): adjudication-reason
amount	0..1	Money	Monetary amount
value	0..1	decimal	Non-monetary value
detail	0..*	BackboneElement	Adjudication for claim details
detailSequenceRequired	1..1	positiveInt	Claim detail instance identifier
noteNumber	0..*	positiveInt	Applicable note numbers
adjudicationRequired	1..*	Same as ClaimResponse.item.adjudication	Detail level adjudication details
subDetail	0..*	BackboneElement	Adjudication for claim sub-details
subDetailSequenceRequired	1..1	positiveInt	Claim sub-detail instance identifier
noteNumber	0..*	positiveInt	Applicable note numbers
adjudication	0..*	Same as ClaimResponse.item.adjudication	Subdetail level adjudication details
addItem	0..*	BackboneElement	Insurer added line items
itemSequence	0..*	positiveInt	Item sequence number
detailSequence	0..*	positiveInt	Detail sequence number
subdetailSequence	0..*	positiveInt	Subdetail sequence number
provider	0..*	Reference(Practitioner | PractitionerRole | Organization)	Authorized providers
productOrServiceRequired	1..1	CodeableConcept	Billing, service, product, or drug codeBinding (example): service-uscls
modifier	0..*	CodeableConcept	Service/Product billing modifiersBinding (example): claim-modifiers
programCode	0..*	CodeableConcept	Program the product or service is provided underBinding (example): ex-program-code
serviced[x]	0..1	date | Period	Date or dates of service or product delivery
location[x]	0..1	CodeableConcept | Address | Reference(Location)	Place of service or where product was suppliedBinding (example): service-place
quantity	0..1	Quantity	Count of products or services
unitPrice	0..1	Money	Fee, charge or cost per item
factor	0..1	decimal	Price scaling factor
net	0..1	Money	Total item cost
bodySite	0..1	CodeableConcept	Anatomical locationBinding (example): tooth
subSite	0..*	CodeableConcept	Anatomical sub-locationBinding (example): surface
noteNumber	0..*	positiveInt	Applicable note numbers
adjudicationRequired	1..*	Same as ClaimResponse.item.adjudication	Added items adjudication
detail	0..*	BackboneElement	Insurer added line details
productOrServiceRequired	1..1	CodeableConcept	Billing, service, product, or drug codeBinding (example): service-uscls
modifier	0..*	CodeableConcept	Service/Product billing modifiersBinding (example): claim-modifiers
quantity	0..1	Quantity	Count of products or services
unitPrice	0..1	Money	Fee, charge or cost per item
factor	0..1	decimal	Price scaling factor
net	0..1	Money	Total item cost
noteNumber	0..*	positiveInt	Applicable note numbers
adjudicationRequired	1..*	Same as ClaimResponse.item.adjudication	Added items detail adjudication
subDetail	0..*	BackboneElement	Insurer added line items
productOrServiceRequired	1..1	CodeableConcept	Billing, service, product, or drug codeBinding (example): service-uscls
modifier	0..*	CodeableConcept	Service/Product billing modifiersBinding (example): claim-modifiers
quantity	0..1	Quantity	Count of products or services
unitPrice	0..1	Money	Fee, charge or cost per item
factor	0..1	decimal	Price scaling factor
net	0..1	Money	Total item cost
noteNumber	0..*	positiveInt	Applicable note numbers
adjudicationRequired	1..*	Same as ClaimResponse.item.adjudication	Added items detail adjudication
adjudication	0..*	Same as ClaimResponse.item.adjudication	Header-level adjudication
totalΣ	0..*	BackboneElement	Adjudication totals
categoryRequiredΣ	1..1	CodeableConcept	Type of adjudication informationBinding (example): adjudication
amountRequiredΣ	1..1	Money	Financial total for the category
payment	0..1	BackboneElement	Payment Details
typeRequired	1..1	CodeableConcept	Partial or complete paymentBinding (example): ex-paymenttype
adjustment	0..1	Money	Payment adjustment for non-claim issues
adjustmentReason	0..1	CodeableConcept	Explanation for the adjustmentBinding (example): payment-adjustment-reason
date	0..1	date	Expected date of payment
amountRequired	1..1	Money	Payable amount after adjustment
identifier	0..1	Identifier	Business identifier for the payment
fundsReserve	0..1	CodeableConcept	Funds reserved statusBinding (example): fundsreserve
formCode	0..1	CodeableConcept	Printed form identifierBinding (example): forms
form	0..1	Attachment	Printed reference or actual form
processNote	0..*	BackboneElement	Note concerning adjudication
number	0..1	positiveInt	Note instance identifier
type	0..1	code	display | print | printoperBinding (required): note-type
textRequired	1..1	string	Note explanatory text
language	0..1	CodeableConcept	Language of the textBinding (preferred): languages
communicationRequest	0..*	Reference(CommunicationRequest)	Request for additional information
insurance	0..*	BackboneElement	Patient insurance information
sequenceRequired	1..1	positiveInt	Insurance instance identifier
focalRequired	1..1	boolean	Coverage to be used for adjudication
coverageRequired	1..1	Reference(Coverage)	Insurance information
businessArrangement	0..1	string	Additional provider contract number
claimResponse	0..1	Reference(ClaimResponse)	Adjudication results
error	0..*	BackboneElement	Processing errors
itemSequence	0..1	positiveInt	Item sequence number
detailSequence	0..1	positiveInt	Detail sequence number
subDetailSequence	0..1	positiveInt	Subdetail sequence number
codeRequired	1..1	CodeableConcept	Error code detailing processing issuesBinding (example): adjudication-error

Σ in _summary results · ?! modifier element · 1.. required · inherited elements in grey

Search parameters

Query with GET [base]/ClaimResponse?[parameter]=[value]. Type decides which modifiers and prefixes apply, see search features.

Parameter	Type	Description	PG	ES
created	date	The creation date ClaimResponse.created
disposition	string	The contents of the disposition message ClaimResponse.disposition
identifier	token	The identity of the ClaimResponse ClaimResponse.identifier
insurer	reference	The organization which generated this resource ClaimResponse.insurer
outcome	token	The processing outcome ClaimResponse.outcome
patient	reference	The subject of care ClaimResponse.patient
payment-date	date	The expected payment date ClaimResponse.payment.date
request	reference	The claim reference ClaimResponse.request
requestor	reference	The Provider of the claim ClaimResponse.requestor
status	token	The status of the ClaimResponse ClaimResponse.status
use	token	The type of claim ClaimResponse.use

PG: PostgreSQL, ES: Elasticsearch. passes its TestScript checks, fails, not tested yet.

Common parameters on every resource (8)

_haste-health-author	reference	The author of the resource
_id	token	Logical id of this artifact
_lastUpdated	date	When the resource version last changed
_profile	uri	Profiles this resource claims to conform to
_security	token	Security Labels applied to this resource
_source	uri	Identifies where the resource comes from
_tag	token	Tags applied to this resource
_type	token	Derived from the R4B Definition