ClaimResponse

A unique identifier assigned to this claim response.

Allows claim responses to be distinguished and referenced.

The status of the resource instance.

Need to track the status of the resource as 'draft' resources may undergo further edits while 'active' resources are immutable and may only have their status changed to 'cancelled'.

This element is labeled as a modifier because the status contains codes that mark the resource as not currently valid.

A code specifying the state of the resource instance.

A finer grained suite of claim type codes which may convey additional information such as Inpatient vs Outpatient and/or a specialty service.

Some jurisdictions need a finer grained claim type for routing and adjudication.

This may contain the local bill type codes, for example the US UB-04 bill type code or the CMS bill type.

The type or discipline-style of the claim.

A finer grained suite of claim type codes which may convey additional information such as Inpatient vs Outpatient and/or a specialty service.

Some jurisdictions need a finer grained claim type for routing and adjudication.

This may contain the local bill type codes, for example the US UB-04 bill type code or the CMS bill type.

A more granular claim typecode.

A code to indicate whether the nature of the request is: to request adjudication of products and services previously rendered; or requesting authorization and adjudication for provision in the future; or requesting the non-binding adjudication of the listed products and services which could be provided in the future.

This element is required to understand the nature of the request for adjudication.

Note that FHIR strings SHALL NOT exceed 1MB in size

Claim, preauthorization, predetermination.

The party to whom the professional services and/or products have been supplied or are being considered and for whom actual for facast reimbursement is sought.

The patient must be supplied to the insurer so that confirmation of coverage and service hstory may be considered as part of the authorization and/or adjudiction.

References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository.

The date this resource was created.

Need to record a timestamp for use by both the recipient and the issuer.

The party responsible for authorization, adjudication and reimbursement.

To be a valid claim, preauthorization or predetermination there must be a party who is responsible for adjudicating the contents against a policy which provides benefits for the patient.

References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository.

The provider which is responsible for the claim, predetermination or preauthorization.

Typically this field would be 1..1 where this party is responsible for the claim but not necessarily professionally responsible for the provision of the individual products and services listed below.

Original request resource reference.

References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository.

The outcome of the claim, predetermination, or preauthorization processing.

To advise the requestor of an overall processing outcome.

The resource may be used to indicate that: the request has been held (queued) for processing; that it has been processed and errors found (error); that no errors were found and that some of the adjudication has been undertaken (partial) or that all of the adjudication has been undertaken (complete).

The result of the claim processing.

A human readable description of the status of the adjudication.

Provided for user display.

Note that FHIR strings SHALL NOT exceed 1MB in size

Reference from the Insurer which is used in later communications which refers to this adjudication.

On subsequent claims, the insurer may require the provider to quote this value.

This value is only present on preauthorization adjudications.

The time frame during which this authorization is effective.

To convey to the provider when the authorized products and services must be supplied for the authorized adjudication to apply.

A Period specifies a range of time; the context of use will specify whether the entire range applies (e.g. "the patient was an inpatient of the hospital for this time range") or one value from the range applies (e.g. "give to the patient between these two times").

Period is not used for a duration (a measure of elapsed time). See Duration.

Type of Party to be reimbursed: subscriber, provider, other.

Need to know who should receive payment with the most common situations being the Provider (assignment of benefits) or the Subscriber.

Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination.

A code for the party to be reimbursed.

A number to uniquely reference the claim item entries.

Necessary to provide a mechanism to link the adjudication result to the submitted claim item.

32 bit number; for values larger than this, use decimal

The numbers associated with notes below which apply to the adjudication of this item.

Provides a condensed manner for associating human readable descriptive explanations for adjudications on the line item.

32 bit number; for values larger than this, use decimal

A code to indicate the information type of this adjudication record. Information types may include the value submitted, maximum values or percentages allowed or payable under the plan, amounts that: the patient is responsible for in aggregate or pertaining to this item; amounts paid by other coverages; and, the benefit payable for this item.

Needed to enable understanding of the context of the other information in the adjudication.

For example codes indicating: Co-Pay, deductible, eligible, benefit, tax, etc.

The adjudication codes.

A code supporting the understanding of the adjudication result and explaining variance from expected amount.

To support understanding of variance from adjudication expectations.

For example may indicate that the funds for this benefit type have been exhausted.

The adjudication reason codes.

Monetary amount associated with the category.

Most adjuciation categories convey a monetary amount.

For example: amount submitted, eligible amount, co-payment, and benefit payable.

A non-monetary value associated with the category. Mutually exclusive to the amount element above.

Some adjudication categories convey a percentage or a fixed value.

For example: eligible percentage or co-payment percentage.

A number to uniquely reference the claim detail entry.

Necessary to provide a mechanism to link the adjudication result to the submitted claim detail.

32 bit number; for values larger than this, use decimal

The numbers associated with notes below which apply to the adjudication of this item.

Provides a condensed manner for associating human readable descriptive explanations for adjudications on the line item.

32 bit number; for values larger than this, use decimal

A number to uniquely reference the claim sub-detail entry.

Necessary to provide a mechanism to link the adjudication result to the submitted claim sub-detail.

32 bit number; for values larger than this, use decimal

The numbers associated with notes below which apply to the adjudication of this item.

Provides a condensed manner for associating human readable descriptive explanations for adjudications on the line item.

32 bit number; for values larger than this, use decimal

Claim items which this service line is intended to replace.

Provides references to the claim items.

32 bit number; for values larger than this, use decimal

The sequence number of the details within the claim item which this line is intended to replace.

Provides references to the claim details within the claim item.

32 bit number; for values larger than this, use decimal

The sequence number of the sub-details within the details within the claim item which this line is intended to replace.

Provides references to the claim sub-details within the claim detail.

32 bit number; for values larger than this, use decimal

The providers who are authorized for the services rendered to the patient.

Insurer may provide authorization specifically to a restricted set of providers rather than an open authorization.

References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository.

When the value is a group code then this item collects a set of related claim details, otherwise this contains the product, service, drug or other billing code for the item.

Necessary to state what was provided or done.

If this is an actual service or product line, i.e. not a Group, then use code to indicate the Professional Service or Product supplied (e.g. CTP, HCPCS, USCLS, ICD10, NCPDP, DIN, RxNorm, ACHI, CCI). If a grouping item then use a group code to indicate the type of thing being grouped e.g. 'glasses' or 'compound'.

Allowable service and product codes.

Item typification or modifiers codes to convey additional context for the product or service.

To support inclusion of the item for adjudication or to charge an elevated fee.

For example in Oral whether the treatment is cosmetic or associated with TMJ, or for Medical whether the treatment was outside the clinic or outside of office hours.

Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.

Identifies the program under which this may be recovered.

Commonly used in in the identification of publicly provided program focused on population segments or disease classifications.

For example: Neonatal program, child dental program or drug users recovery program.

Program specific reason codes.

The number of repetitions of a service or product.

Required when the product or service code does not convey the quantity provided.

The context of use may frequently define what kind of quantity this is and therefore what kind of units can be used. The context of use may also restrict the values for the comparator.

If the item is not a group then this is the fee for the product or service, otherwise this is the total of the fees for the details of the group.

The amount charged to the patient by the provider for a single unit.

A real number that represents a multiplier used in determining the overall value of services delivered and/or goods received. The concept of a Factor allows for a discount or surcharge multiplier to be applied to a monetary amount.

When discounts are provided to a patient (example: Senior's discount) then this must be documented for adjudication.

To show a 10% senior's discount, the value entered is: 0.90 (1.00 - 0.10).

The quantity times the unit price for an additional service or product or charge.

Provides the total amount claimed for the group (if a grouper) or the line item.

For example, the formula: quantity * unitPrice * factor = net. Quantity and factor are assumed to be 1 if not supplied.

Physical service site on the patient (limb, tooth, etc.).

Allows insurer to validate specific procedures.

For example: Providing a tooth code allows an insurer to identify a provider performing a filling on a tooth that was previously removed.

The code for the teeth, quadrant, sextant and arch.

A region or surface of the bodySite, e.g. limb region or tooth surface(s).

Allows insurer to validate specific procedures.

Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination.

The code for the tooth surface and surface combinations.

The numbers associated with notes below which apply to the adjudication of this item.

Provides a condensed manner for associating human readable descriptive explanations for adjudications on the line item.

32 bit number; for values larger than this, use decimal

When the value is a group code then this item collects a set of related claim details, otherwise this contains the product, service, drug or other billing code for the item.

Necessary to state what was provided or done.

If this is an actual service or product line, i.e. not a Group, then use code to indicate the Professional Service or Product supplied (e.g. CTP, HCPCS, USCLS, ICD10, NCPDP, DIN, RxNorm, ACHI, CCI). If a grouping item then use a group code to indicate the type of thing being grouped e.g. 'glasses' or 'compound'.

Allowable service and product codes.

Item typification or modifiers codes to convey additional context for the product or service.

To support inclusion of the item for adjudication or to charge an elevated fee.

For example in Oral whether the treatment is cosmetic or associated with TMJ, or for Medical whether the treatment was outside the clinic or outside of office hours.

Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.

The number of repetitions of a service or product.

Required when the product or service code does not convey the quantity provided.

The context of use may frequently define what kind of quantity this is and therefore what kind of units can be used. The context of use may also restrict the values for the comparator.

If the item is not a group then this is the fee for the product or service, otherwise this is the total of the fees for the details of the group.

The amount charged to the patient by the provider for a single unit.

A real number that represents a multiplier used in determining the overall value of services delivered and/or goods received. The concept of a Factor allows for a discount or surcharge multiplier to be applied to a monetary amount.

When discounts are provided to a patient (example: Senior's discount) then this must be documented for adjudication.

To show a 10% senior's discount, the value entered is: 0.90 (1.00 - 0.10).

The quantity times the unit price for an additional service or product or charge.

Provides the total amount claimed for the group (if a grouper) or the line item.

For example, the formula: quantity * unitPrice * factor = net. Quantity and factor are assumed to be 1 if not supplied.

The numbers associated with notes below which apply to the adjudication of this item.

Provides a condensed manner for associating human readable descriptive explanations for adjudications on the line item.

32 bit number; for values larger than this, use decimal

When the value is a group code then this item collects a set of related claim details, otherwise this contains the product, service, drug or other billing code for the item.

Necessary to state what was provided or done.

If this is an actual service or product line, i.e. not a Group, then use code to indicate the Professional Service or Product supplied (e.g. CTP, HCPCS, USCLS, ICD10, NCPDP, DIN, RxNorm, ACHI, CCI). If a grouping item then use a group code to indicate the type of thing being grouped e.g. 'glasses' or 'compound'.

Allowable service and product codes.

Item typification or modifiers codes to convey additional context for the product or service.

To support inclusion of the item for adjudication or to charge an elevated fee.

For example in Oral whether the treatment is cosmetic or associated with TMJ, or for Medical whether the treatment was outside the clinic or outside of office hours.

Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.

The number of repetitions of a service or product.

Required when the product or service code does not convey the quantity provided.

The context of use may frequently define what kind of quantity this is and therefore what kind of units can be used. The context of use may also restrict the values for the comparator.

If the item is not a group then this is the fee for the product or service, otherwise this is the total of the fees for the details of the group.

The amount charged to the patient by the provider for a single unit.

A real number that represents a multiplier used in determining the overall value of services delivered and/or goods received. The concept of a Factor allows for a discount or surcharge multiplier to be applied to a monetary amount.

When discounts are provided to a patient (example: Senior's discount) then this must be documented for adjudication.

To show a 10% senior's discount, the value entered is: 0.90 (1.00 - 0.10).

The quantity times the unit price for an additional service or product or charge.

Provides the total amount claimed for the group (if a grouper) or the line item.

For example, the formula: quantity * unitPrice * factor = net. Quantity and factor are assumed to be 1 if not supplied.

The numbers associated with notes below which apply to the adjudication of this item.

Provides a condensed manner for associating human readable descriptive explanations for adjudications on the line item.

32 bit number; for values larger than this, use decimal

A code to indicate the information type of this adjudication record. Information types may include: the value submitted, maximum values or percentages allowed or payable under the plan, amounts that the patient is responsible for in aggregate or pertaining to this item, amounts paid by other coverages, and the benefit payable for this item.

Needed to convey the type of total provided.

For example codes indicating: Co-Pay, deductible, eligible, benefit, tax, etc.

The adjudication codes.

Monetary total amount associated with the category.

Needed to convey the total monetary amount.

Whether this represents partial or complete payment of the benefits payable.

To advise the requestor when the insurer believes all payments to have been completed.

Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination.

The type (partial, complete) of the payment.

Total amount of all adjustments to this payment included in this transaction which are not related to this claim's adjudication.

To advise the requestor of adjustments applied to the payment.

Insurers will deduct amounts owing from the provider (adjustment), such as a prior overpayment, from the amount owing to the provider (benefits payable) when payment is made to the provider.

Reason for the payment adjustment.

Needed to clarify the monetary adjustment.

Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination.

Payment Adjustment reason codes.

Estimated date the payment will be issued or the actual issue date of payment.

To advise the payee when payment can be expected.

Benefits payable less any payment adjustment.

Needed to provide the actual payment amount.

Issuer's unique identifier for the payment instrument.

Enable the receiver to reconcile when payment received.

For example: EFT number or check number.

A code, used only on a response to a preauthorization, to indicate whether the benefits payable have been reserved and for whom.

Needed to advise the submitting provider on whether the rquest for reservation of funds has been honored.

Fund would be release by a future claim quoting the preAuthRef of this response. Examples of values include: provider, patient, none.

For whom funds are to be reserved: (Patient, Provider, None).

A code for the form to be used for printing the content.

Needed to specify the specific form used for producing output for this response.

May be needed to identify specific jurisdictional forms.

The forms codes.

The actual form, by reference or inclusion, for printing the content or an EOB.

Needed to include the specific form used for producing output for this response.

Needed to permit insurers to include the actual form.

A number to uniquely identify a note entry.

Necessary to provide a mechanism to link from adjudications.

32 bit number; for values larger than this, use decimal

The business purpose of the note text.

To convey the expectation for when the text is used.

Note that FHIR strings SHALL NOT exceed 1MB in size

The presentation types of notes.

The explanation or description associated with the processing.

Required to provide human readable explanation.

Note that FHIR strings SHALL NOT exceed 1MB in size

A code to define the language used in the text of the note.

Note text may vary from the resource defined language.

Only required if the language is different from the resource language.

A human language.

Request for additional supporting or authorizing information.

Need to communicate insurer request for additional information required to support the adjudication.

For example: professional reports, documents, images, clinical resources, or accident reports.

A number to uniquely identify insurance entries and provide a sequence of coverages to convey coordination of benefit order.

To maintain order of the coverages.

32 bit number; for values larger than this, use decimal

A flag to indicate that this Coverage is to be used for adjudication of this claim when set to true.

To identify which coverage in the list is being used to adjudicate this claim.

A patient may (will) have multiple insurance policies which provide reimbursement for healthcare services and products. For example a person may also be covered by their spouse's policy and both appear in the list (and may be from the same insurer). This flag will be set to true for only one of the listed policies and that policy will be used for adjudicating this claim. Other claims would be created to request adjudication against the other listed policies.

Reference to the insurance card level information contained in the Coverage resource. The coverage issuing insurer will use these details to locate the patient's actual coverage within the insurer's information system.

Required to allow the adjudicator to locate the correct policy and history within their information system.

References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository.

A business agreement number established between the provider and the insurer for special business processing purposes.

Providers may have multiple business arrangements with a given insurer and must supply the specific contract number for adjudication.

Note that FHIR strings SHALL NOT exceed 1MB in size

The result of the adjudication of the line items for the Coverage specified in this insurance.

An insurer need the adjudication results from prior insurers to determine the outstanding balance remaining by item for the items in the curent claim.

Must not be specified when 'focal=true' for this insurance.