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

... traceNumber 0..*IdentifierNumber for tracking

... status ?!Σ1..1codeactive | cancelled | draft | entered-in-error
Binding: Financial Resource Status Codes (Required)
... type Σ1..1CodeableConceptMore granular claim type
Binding: Claim Type Codes (Extensible)
... subType 0..1CodeableConceptMore granular claim type
Binding: Example Claim SubType Codes (Example)
... use Σ1..1codeclaim | preauthorization | predetermination
Binding: Use (Required)
... patient Σ1..1Reference(Patient)The recipient of the products and services
... created Σ1..1dateTimeResponse creation date
... insurer Σ0..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
Binding: Claim Processing Codes (Required)
... decision Σ0..1CodeableConceptResult of the adjudication
Binding: Claim Adjudication Decision Codes (Example)
... disposition 0..1stringDisposition Message
... preAuthRef 0..1stringPreauthorization reference
... preAuthPeriod 0..1PeriodPreauthorization reference effective period
... event 0..*BackboneElementEvent information

.... type 1..1CodeableConceptSpecific event
Binding: Dates Type Codes (Example)
.... when[x] 1..1Occurance date or period
..... whenDateTimedateTime
..... whenPeriodPeriod
... payeeType 0..1CodeableConceptParty to be paid any benefits payable
Binding: Claim Payee Type Codes (Example)
... encounter 0..*Reference(Encounter)Encounters associated with the listed treatments

... diagnosisRelatedGroup 0..1CodeableConceptPackage billing code
Binding: Example Diagnosis Related Group Codes (Example)
... item 0..*BackboneElementAdjudication for claim line items

.... itemSequence 1..1positiveIntClaim item instance identifier
.... traceNumber 0..*IdentifierNumber for tracking

.... noteNumber 0..*positiveIntApplicable note numbers

.... reviewOutcome 0..1BackboneElementAdjudication results
..... decision 0..1CodeableConceptResult of the adjudication
Binding: Claim Adjudication Decision Codes (Example)
..... reason 0..*CodeableConceptReason for result of the adjudication
Binding: Claim Adjudication Decision Reason Codes (Example)

..... preAuthRef 0..1stringPreauthorization reference
..... preAuthPeriod 0..1PeriodPreauthorization reference effective period
.... adjudication 0..*BackboneElementAdjudication details

..... category 1..1CodeableConceptType of adjudication information
Binding: Adjudication Value Codes (Example)
..... reason 0..1CodeableConceptExplanation of adjudication outcome
Binding: Adjudication Reason Codes (Example)
..... amount 0..1MoneyMonetary amount
..... quantity 0..1QuantityNon-monetary value
.... detail 0..*BackboneElementAdjudication for claim details

..... detailSequence 1..1positiveIntClaim detail instance identifier
..... traceNumber 0..*IdentifierNumber for tracking

..... noteNumber 0..*positiveIntApplicable note numbers

..... reviewOutcome 0..1see reviewOutcomeDetail level adjudication results
..... adjudication 0..*see adjudicationDetail level adjudication details

..... subDetail 0..*BackboneElementAdjudication for claim sub-details

...... subDetailSequence 1..1positiveIntClaim sub-detail instance identifier
...... traceNumber 0..*IdentifierNumber for tracking

...... noteNumber 0..*positiveIntApplicable note numbers

...... reviewOutcome 0..1see reviewOutcomeSubdetail level adjudication results
...... 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

.... traceNumber 0..*IdentifierNumber for tracking

.... provider 0..*Reference(Practitioner | PractitionerRole | Organization)Authorized providers

.... revenue 0..1CodeableConceptRevenue or cost center code
Binding: Example Revenue Center Codes (Example)
.... productOrService 0..1CodeableConceptBilling, service, product, or drug code
Binding: USCLS Codes (Example)
.... productOrServiceEnd 0..1CodeableConceptEnd of a range of codes
Binding: USCLS Codes (Example)
.... request 0..*Reference(DeviceRequest | MedicationRequest | NutritionOrder | ServiceRequest | SupplyRequest | VisionPrescription)Request or Referral for Service

.... modifier 0..*CodeableConceptService/Product billing modifiers
Binding: Modifier type Codes (Example)

.... programCode 0..*CodeableConceptProgram the product or service is provided under
Binding: 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
Binding: 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
.... tax 0..1MoneyTotal tax
.... net 0..1MoneyTotal item cost
.... bodySite 0..*BackboneElementAnatomical location

..... site 1..*CodeableReference(BodyStructure)Location
Binding: Oral Site Codes (Example)

..... subSite 0..*CodeableConceptSub-location
Binding: Surface Codes (Example)

.... noteNumber 0..*positiveIntApplicable note numbers

.... reviewOutcome 0..1see reviewOutcomeAdded items adjudication results
.... adjudication 0..*see adjudicationAdded items adjudication

.... detail 0..*BackboneElementInsurer added line details

..... traceNumber 0..*IdentifierNumber for tracking

..... revenue 0..1CodeableConceptRevenue or cost center code
Binding: Example Revenue Center Codes (Example)
..... productOrService 0..1CodeableConceptBilling, service, product, or drug code
Binding: USCLS Codes (Example)
..... productOrServiceEnd 0..1CodeableConceptEnd of a range of codes
Binding: USCLS Codes (Example)
..... modifier 0..*CodeableConceptService/Product billing modifiers
Binding: Modifier type Codes (Example)

..... quantity 0..1SimpleQuantityCount of products or services
..... unitPrice 0..1MoneyFee, charge or cost per item
..... factor 0..1decimalPrice scaling factor
..... tax 0..1MoneyTotal tax
..... net 0..1MoneyTotal item cost
..... noteNumber 0..*positiveIntApplicable note numbers

..... reviewOutcome 0..1see reviewOutcomeAdded items detail level adjudication results
..... adjudication 0..*see adjudicationAdded items detail adjudication

..... subDetail 0..*BackboneElementInsurer added line items

...... traceNumber 0..*IdentifierNumber for tracking

...... revenue 0..1CodeableConceptRevenue or cost center code
Binding: Example Revenue Center Codes (Example)
...... productOrService 0..1CodeableConceptBilling, service, product, or drug code
Binding: USCLS Codes (Example)
...... productOrServiceEnd 0..1CodeableConceptEnd of a range of codes
Binding: USCLS Codes (Example)
...... modifier 0..*CodeableConceptService/Product billing modifiers
Binding: Modifier type Codes (Example)

...... quantity 0..1SimpleQuantityCount of products or services
...... unitPrice 0..1MoneyFee, charge or cost per item
...... factor 0..1decimalPrice scaling factor
...... tax 0..1MoneyTotal tax
...... net 0..1MoneyTotal item cost
...... noteNumber 0..*positiveIntApplicable note numbers

...... reviewOutcome 0..1see reviewOutcomeAdded items subdetail level adjudication results
...... adjudication 0..*see adjudicationAdded items subdetail adjudication

... adjudication 0..*see adjudicationHeader-level adjudication

... total Σ0..*BackboneElementAdjudication totals

.... category Σ1..1CodeableConceptType of adjudication information
Binding: Adjudication Value Codes (Example)
.... amount Σ1..1MoneyFinancial total for the category
... payment 0..1BackboneElementPayment Details
.... type 1..1CodeableConceptPartial or complete payment
Binding: Example Payment Type Codes (Example)
.... adjustment 0..1MoneyPayment adjustment for non-claim issues
.... adjustmentReason 0..1CodeableConceptExplanation for the adjustment
Binding: 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
Binding: Funds Reservation Codes (Example)
... formCode 0..1CodeableConceptPrinted form identifier
Binding: Form Codes (Example)
... form 0..1AttachmentPrinted reference or actual form
... processNote 0..*BackboneElementNote concerning adjudication

.... number 0..1positiveIntNote instance identifier
.... type 0..1CodeableConceptNote purpose
Binding: NoteType (Extensible)
.... text 1..1stringNote explanatory text
.... language 0..1CodeableConceptLanguage of the text
Binding: All Languages (Required)
Additional BindingsPurpose
Common LanguagesStarter Set

... 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 Σ1..1CodeableConceptError code detailing processing issues
Binding: Adjudication Error Codes (Example)
.... expression Σ0..*stringFHIRPath of element(s) related to issue


doco Documentation for this format