Name Flags Card. Type Description & Constraints doco
. . ClaimResponse TU DomainResource Response to a claim predetermination or preauthorization
Elements defined in Ancestors: id, meta, implicitRules, language, text, contained, extension, modifierExtension
. . . identifier 0..* Identifier Business Identifier for a claim response
. . . status ?! Σ 1..1 code active | cancelled | draft | entered-in-error
Financial Resource Status Codes (Required)
. . . type Σ 1..1 CodeableConcept More granular claim type
Claim Type Codes (Extensible)
. . . subType 0..1 CodeableConcept More granular claim type
Example Claim SubType Codes (Example)
. . . use Σ 1..1 code claim | preauthorization | predetermination
Use (Required)
. . . patient Σ 1..1 Reference(Patient) The recipient of the products and services
. . . created Σ 1..1 dateTime Response creation date
. . . insurer Σ 1..1 Reference(Organization) Party responsible for reimbursement
. . . requestor 0..1 Reference(Practitioner | PractitionerRole | Organization) Party responsible for the claim
. . . request Σ 0..1 Reference(Claim) Id of resource triggering adjudication
. . . outcome Σ 1..1 code queued | complete | error | partial
Claim Processing Codes (Required)
. . . 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 payable
PayeeType (Example)
. . . item 0..* BackboneElement Adjudication for claim line items
. . . . itemSequence 1..1 positiveInt Claim item instance identifier
. . . . noteNumber 0..* positiveInt Applicable note numbers
. . . . adjudication 1..* BackboneElement Adjudication details
. . . . . category 1..1 CodeableConcept Type of adjudication information
Adjudication Value Codes (Example)
. . . . . reason 0..1 CodeableConcept Explanation of adjudication outcome
Adjudication Reason Codes (Example)
. . . . . amount 0..1 Money Monetary amount
. . . . . value 0..1 decimal Non-monetary value
. . . . detail 0..* BackboneElement Adjudication for claim details
. . . . . detailSequence 1..1 positiveInt Claim detail instance identifier
. . . . . noteNumber 0..* positiveInt Applicable note numbers
. . . . . adjudication 1..* see adjudication Detail level adjudication details
. . . . . subDetail 0..* BackboneElement Adjudication for claim sub-details
. . . . . . subDetailSequence 1..1 positiveInt Claim sub-detail instance identifier
. . . . . . noteNumber 0..* positiveInt Applicable note numbers
. . . . . . adjudication 0..* see 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
. . . . productOrService 1..1 CodeableConcept Billing, service, product, or drug code
USCLS Codes (Example)
. . . . modifier 0..* CodeableConcept Service/Product billing modifiers
Modifier type Codes (Example)
. . . . programCode 0..* CodeableConcept Program the product or service is provided under
Example Program Reason Codes (Example)
. . . . serviced[x] 0..1 Date or dates of service or product delivery
. . . . . servicedDate date
. . . . . servicedPeriod Period
. . . . location[x] 0..1 Place of service or where product was supplied
Example Service Place Codes (Example)
. . . . . locationCodeableConcept CodeableConcept
. . . . . locationAddress Address
. . . . . locationReference Reference(Location)
. . . . quantity 0..1 SimpleQuantity 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 location
Oral Site Codes (Example)
. . . . subSite 0..* CodeableConcept Anatomical sub-location
Surface Codes (Example)
. . . . noteNumber 0..* positiveInt Applicable note numbers
. . . . adjudication 1..* see adjudication Added items adjudication
. . . . detail 0..* BackboneElement Insurer added line details
. . . . . productOrService 1..1 CodeableConcept Billing, service, product, or drug code
USCLS Codes (Example)
. . . . . modifier 0..* CodeableConcept Service/Product billing modifiers
Modifier type Codes (Example)
. . . . . quantity 0..1 SimpleQuantity 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
. . . . . adjudication 1..* see adjudication Added items detail adjudication
. . . . . subDetail 0..* BackboneElement Insurer added line items
. . . . . . productOrService 1..1 CodeableConcept Billing, service, product, or drug code
USCLS Codes (Example)
. . . . . . modifier 0..* CodeableConcept Service/Product billing modifiers
Modifier type Codes (Example)
. . . . . . quantity 0..1 SimpleQuantity 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
. . . . . . adjudication 1..* see adjudication Added items detail adjudication
. . . adjudication 0..* see adjudication Header-level adjudication
. . . total Σ 0..* BackboneElement Adjudication totals
. . . . category Σ 1..1 CodeableConcept Type of adjudication information
Adjudication Value Codes (Example)
. . . . amount Σ 1..1 Money Financial total for the category
. . . payment 0..1 BackboneElement Payment Details
. . . . type 1..1 CodeableConcept Partial or complete payment
Example Payment Type Codes (Example)
. . . . adjustment 0..1 Money Payment adjustment for non-claim issues
. . . . adjustmentReason 0..1 CodeableConcept Explanation for the adjustment
Payment Adjustment Reason Codes (Example)
. . . . date 0..1 date Expected date of payment
. . . . amount 1..1 Money Payable amount after adjustment
. . . . identifier 0..1 Identifier Business identifier for the payment
. . . fundsReserve 0..1 CodeableConcept Funds reserved status
FundsReserve (Example)
. . . formCode 0..1 CodeableConcept Printed form identifier
Forms (Example)
. . . 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 | printoper
NoteType (Required)
. . . . text 1..1 string Note explanatory text
. . . . language 0..1 CodeableConcept Language of the text
Common Languages (Preferred but limited to AllLanguages)
. . . communicationRequest 0..* Reference(CommunicationRequest) Request for additional information
. . . insurance 0..* BackboneElement Patient insurance information
. . . . sequence 1..1 positiveInt Insurance instance identifier
. . . . focal 1..1 boolean Coverage to be used for adjudication
. . . . coverage 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
. . . . code 1..1 CodeableConcept Error code detailing processing issues
AdjudicationError (Example)

doco Documentation for this format