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Financial Management Work GroupMaturity Level: 2 Trial UseSecurity Category: Patient Compartments: Patient, Practitioner

Detailed Descriptions for the elements in the ClaimResponse resource.

ClaimResponse
Element IdClaimResponse
Definition

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

Cardinality0..*
TypeDomainResource
Alternate NamesRemittance Advice
ClaimResponse.identifier
Element IdClaimResponse.identifier
Definition

A unique identifier assigned to this claim response.

NoteThis is a business identifier, not a resource identifier (see discussion)
Cardinality0..*
TypeIdentifier
Requirements

Allows claim responses to be distinguished and referenced.

ClaimResponse.status
Element IdClaimResponse.status
Definition

The status of the resource instance.

Cardinality1..1
Terminology BindingFinancial Resource Status Codes (Required)
Typecode
Is Modifiertrue (Reason: This element is labeled as a modifier because it is a status element that contains status entered-in-error which means that the resource should not be treated as valid)
Requirements

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'.

Summarytrue
Comments

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

ClaimResponse.type
Element IdClaimResponse.type
Definition

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

Cardinality1..1
Terminology BindingClaim Type Codes (Extensible)
TypeCodeableConcept
Requirements

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

Summarytrue
Comments

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

ClaimResponse.subType
Element IdClaimResponse.subType
Definition

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

Cardinality0..1
Terminology BindingExample Claim SubType Codes (Example)
TypeCodeableConcept
Requirements

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

Comments

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

ClaimResponse.use
Element IdClaimResponse.use
Definition

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.

Cardinality1..1
Terminology BindingUse (Required)
Typecode
Requirements

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

Summarytrue
ClaimResponse.patient
Element IdClaimResponse.patient
Definition

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.

Cardinality1..1
TypeReference(Patient)
Requirements

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.

Summarytrue
ClaimResponse.created
Element IdClaimResponse.created
Definition

The date this resource was created.

Cardinality1..1
TypedateTime
Requirements

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

Summarytrue
ClaimResponse.insurer
Element IdClaimResponse.insurer
Definition

The party responsible for authorization, adjudication and reimbursement.

Cardinality1..1
TypeReference(Organization)
Requirements

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.

Summarytrue
ClaimResponse.requestor
Element IdClaimResponse.requestor
Definition

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

Cardinality0..1
TypeReference(Practitioner | PractitionerRole | Organization)
PatternsReference(Practitioner,PractitionerRole,Organization): Common patterns = Participant
Comments

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.

ClaimResponse.request
Element IdClaimResponse.request
Definition

Original request resource reference.

Cardinality0..1
TypeReference(Claim)
Summarytrue
ClaimResponse.outcome
Element IdClaimResponse.outcome
Definition

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

Cardinality1..1
Terminology BindingClaim Processing Codes (Required)
Typecode
Requirements

To advise the requestor of an overall processing outcome.

Summarytrue
Comments

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).

ClaimResponse.disposition
Element IdClaimResponse.disposition
Definition

A human readable description of the status of the adjudication.

Cardinality0..1
Typestring
Requirements

Provided for user display.

ClaimResponse.preAuthRef
Element IdClaimResponse.preAuthRef
Definition

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

Cardinality0..1
Typestring
Requirements

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

Comments

This value is only present on preauthorization adjudications.

ClaimResponse.preAuthPeriod
Element IdClaimResponse.preAuthPeriod
Definition

The time frame during which this authorization is effective.

Cardinality0..1
TypePeriod
Requirements

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

ClaimResponse.payeeType
Element IdClaimResponse.payeeType
Definition

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

Cardinality0..1
Terminology BindingPayeeType (Example)
TypeCodeableConcept
Requirements

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

ClaimResponse.item
Element IdClaimResponse.item
Definition

A claim line. Either a simple (a product or service) or a 'group' of details which can also be a simple items or groups of sub-details.

Cardinality0..*
Requirements

The adjudication for items provided on the claim.

ClaimResponse.item.itemSequence
Element IdClaimResponse.item.itemSequence
Definition

A number to uniquely reference the claim item entries.

Cardinality1..1
TypepositiveInt
Requirements

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

ClaimResponse.item.noteNumber
Element IdClaimResponse.item.noteNumber
Definition

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

Cardinality0..*
TypepositiveInt
Requirements

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

ClaimResponse.item.adjudication
Element IdClaimResponse.item.adjudication
Definition

If this item is a group then the values here are a summary of the adjudication of the detail items. If this item is a simple product or service then this is the result of the adjudication of this item.

Cardinality1..*
Requirements

The adjudication results conveys the insurer's assessment of the item provided in the claim under the terms of the patient's insurance coverage.

ClaimResponse.item.adjudication.category
Element IdClaimResponse.item.adjudication.category
Definition

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.

Cardinality1..1
Terminology BindingAdjudication Value Codes (Example)
TypeCodeableConcept
Requirements

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

Comments

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

ClaimResponse.item.adjudication.reason
Element IdClaimResponse.item.adjudication.reason
Definition

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

Cardinality0..1
Terminology BindingAdjudication Reason Codes (Example)
TypeCodeableConcept
Requirements

To support understanding of variance from adjudication expectations.

Comments

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

ClaimResponse.item.adjudication.amount
Element IdClaimResponse.item.adjudication.amount
Definition

Monetary amount associated with the category.

Cardinality0..1
TypeMoney
Requirements

Most adjuciation categories convey a monetary amount.

Comments

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

ClaimResponse.item.adjudication.value
Element IdClaimResponse.item.adjudication.value
Definition

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

Cardinality0..1
Typedecimal
Requirements

Some adjudication categories convey a percentage or a fixed value.

Comments

For example: eligible percentage or co-payment percentage.

ClaimResponse.item.detail
Element IdClaimResponse.item.detail
Definition

A claim detail. Either a simple (a product or service) or a 'group' of sub-details which are simple items.

Cardinality0..*
Requirements

The adjudication for details provided on the claim.

ClaimResponse.item.detail.detailSequence
Element IdClaimResponse.item.detail.detailSequence
Definition

A number to uniquely reference the claim detail entry.

Cardinality1..1
TypepositiveInt
Requirements

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

ClaimResponse.item.detail.noteNumber
Element IdClaimResponse.item.detail.noteNumber
Definition

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

Cardinality0..*
TypepositiveInt
Requirements

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

ClaimResponse.item.detail.adjudication
Element IdClaimResponse.item.detail.adjudication
Definition

The adjudication results.

Cardinality1..*
TypeSee ClaimResponse.item.adjudication
ClaimResponse.item.detail.subDetail
Element IdClaimResponse.item.detail.subDetail
Definition

A sub-detail adjudication of a simple product or service.

Cardinality0..*
Requirements

The adjudication for sub-details provided on the claim.

ClaimResponse.item.detail.subDetail.subDetailSequence
Element IdClaimResponse.item.detail.subDetail.subDetailSequence
Definition

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

Cardinality1..1
TypepositiveInt
Requirements

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

ClaimResponse.item.detail.subDetail.noteNumber
Element IdClaimResponse.item.detail.subDetail.noteNumber
Definition

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

Cardinality0..*
TypepositiveInt
Requirements

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

ClaimResponse.item.detail.subDetail.adjudication
Element IdClaimResponse.item.detail.subDetail.adjudication
Definition

The adjudication results.

Cardinality0..*
TypeSee ClaimResponse.item.adjudication
ClaimResponse.addItem
Element IdClaimResponse.addItem
Definition

The first-tier service adjudications for payor added product or service lines.

Cardinality0..*
Requirements

Insurers may redefine the provided product or service or may package and/or decompose groups of products and services. The addItems allows the insurer to provide their line item list with linkage to the submitted items/details/sub-details. In a preauthorization the insurer may use the addItem structure to provide additional information on authorized products and services.

ClaimResponse.addItem.itemSequence
Element IdClaimResponse.addItem.itemSequence
Definition

Claim items which this service line is intended to replace.

Cardinality0..*
TypepositiveInt
Requirements

Provides references to the claim items.

ClaimResponse.addItem.detailSequence
Element IdClaimResponse.addItem.detailSequence
Definition

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

Cardinality0..*
TypepositiveInt
Requirements

Provides references to the claim details within the claim item.

ClaimResponse.addItem.subdetailSequence
Element IdClaimResponse.addItem.subdetailSequence
Definition

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

Cardinality0..*
TypepositiveInt
Requirements

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

ClaimResponse.addItem.provider
Element IdClaimResponse.addItem.provider
Definition

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

Cardinality0..*
TypeReference(Practitioner | PractitionerRole | Organization)
PatternsReference(Practitioner,PractitionerRole,Organization): Common patterns = Participant
Requirements

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

ClaimResponse.addItem.productOrService
Element IdClaimResponse.addItem.productOrService
Definition

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.

Cardinality1..1
Terminology BindingUSCLS Codes (Example)
TypeCodeableConcept
Requirements

Necessary to state what was provided or done.

Comments

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'.

ClaimResponse.addItem.modifier
Element IdClaimResponse.addItem.modifier
Definition

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

Cardinality0..*
Terminology BindingModifier type Codes (Example)
TypeCodeableConcept
Requirements

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

Comments

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.

ClaimResponse.addItem.programCode
Element IdClaimResponse.addItem.programCode
Definition

Identifies the program under which this may be recovered.

Cardinality0..*
Terminology BindingExample Program Reason Codes (Example)
TypeCodeableConcept
Requirements

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

Comments

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

ClaimResponse.addItem.serviced[x]
Element IdClaimResponse.addItem.serviced[x]
Definition

The date or dates when the service or product was supplied, performed or completed.

Cardinality0..1
Typedate|Period
[x] NoteSee Choice of Data Types for further information about how to use [x]
Requirements

Needed to determine whether the service or product was provided during the term of the insurance coverage.

ClaimResponse.addItem.location[x]
Element IdClaimResponse.addItem.location[x]
Definition

Where the product or service was provided.

Cardinality0..1
Terminology BindingExample Service Place Codes (Example)
TypeCodeableConcept|Address|Reference(Location)
[x] NoteSee Choice of Data Types for further information about how to use [x]
Requirements

The location can alter whether the item was acceptable for insurance purposes or impact the determination of the benefit amount.

ClaimResponse.addItem.quantity
Element IdClaimResponse.addItem.quantity
Definition

The number of repetitions of a service or product.

Cardinality0..1
TypeSimpleQuantity
Requirements

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

ClaimResponse.addItem.unitPrice
Element IdClaimResponse.addItem.unitPrice
Definition

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.

Cardinality0..1
TypeMoney
Requirements

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

ClaimResponse.addItem.factor
Element IdClaimResponse.addItem.factor
Definition

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.

Cardinality0..1
Typedecimal
Requirements

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

Comments

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

ClaimResponse.addItem.net
Element IdClaimResponse.addItem.net
Definition

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

Cardinality0..1
TypeMoney
Requirements

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

Comments

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

ClaimResponse.addItem.bodySite
Element IdClaimResponse.addItem.bodySite
Definition

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

Cardinality0..1
Terminology BindingOral Site Codes (Example)
TypeCodeableConcept
Requirements

Allows insurer to validate specific procedures.

Comments

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

ClaimResponse.addItem.subSite
Element IdClaimResponse.addItem.subSite
Definition

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

Cardinality0..*
Terminology BindingSurface Codes (Example)
TypeCodeableConcept
Requirements

Allows insurer to validate specific procedures.

ClaimResponse.addItem.noteNumber
Element IdClaimResponse.addItem.noteNumber
Definition

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

Cardinality0..*
TypepositiveInt
Requirements

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

ClaimResponse.addItem.adjudication
Element IdClaimResponse.addItem.adjudication
Definition

The adjudication results.

Cardinality1..*
TypeSee ClaimResponse.item.adjudication
ClaimResponse.addItem.detail
Element IdClaimResponse.addItem.detail
Definition

The second-tier service adjudications for payor added services.

Cardinality0..*
ClaimResponse.addItem.detail.productOrService
Element IdClaimResponse.addItem.detail.productOrService
Definition

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.

Cardinality1..1
Terminology BindingUSCLS Codes (Example)
TypeCodeableConcept
Requirements

Necessary to state what was provided or done.

Comments

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'.

ClaimResponse.addItem.detail.modifier
Element IdClaimResponse.addItem.detail.modifier
Definition

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

Cardinality0..*
Terminology BindingModifier type Codes (Example)
TypeCodeableConcept
Requirements

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

Comments

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.

ClaimResponse.addItem.detail.quantity
Element IdClaimResponse.addItem.detail.quantity
Definition

The number of repetitions of a service or product.

Cardinality0..1
TypeSimpleQuantity
Requirements

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

ClaimResponse.addItem.detail.unitPrice
Element IdClaimResponse.addItem.detail.unitPrice
Definition

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.

Cardinality0..1
TypeMoney
Requirements

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

ClaimResponse.addItem.detail.factor
Element IdClaimResponse.addItem.detail.factor
Definition

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.

Cardinality0..1
Typedecimal
Requirements

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

Comments

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

ClaimResponse.addItem.detail.net
Element IdClaimResponse.addItem.detail.net
Definition

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

Cardinality0..1
TypeMoney
Requirements

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

Comments

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

ClaimResponse.addItem.detail.noteNumber
Element IdClaimResponse.addItem.detail.noteNumber
Definition

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

Cardinality0..*
TypepositiveInt
Requirements

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

ClaimResponse.addItem.detail.adjudication
Element IdClaimResponse.addItem.detail.adjudication
Definition

The adjudication results.

Cardinality1..*
TypeSee ClaimResponse.item.adjudication
ClaimResponse.addItem.detail.subDetail
Element IdClaimResponse.addItem.detail.subDetail
Definition

The third-tier service adjudications for payor added services.

Cardinality0..*
ClaimResponse.addItem.detail.subDetail.productOrService
Element IdClaimResponse.addItem.detail.subDetail.productOrService
Definition

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.

Cardinality1..1
Terminology BindingUSCLS Codes (Example)
TypeCodeableConcept
Requirements

Necessary to state what was provided or done.

Comments

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'.

ClaimResponse.addItem.detail.subDetail.modifier
Element IdClaimResponse.addItem.detail.subDetail.modifier
Definition

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

Cardinality0..*
Terminology BindingModifier type Codes (Example)
TypeCodeableConcept
Requirements

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

Comments

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.

ClaimResponse.addItem.detail.subDetail.quantity
Element IdClaimResponse.addItem.detail.subDetail.quantity
Definition

The number of repetitions of a service or product.

Cardinality0..1
TypeSimpleQuantity
Requirements

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

ClaimResponse.addItem.detail.subDetail.unitPrice
Element IdClaimResponse.addItem.detail.subDetail.unitPrice
Definition

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.

Cardinality0..1
TypeMoney
Requirements

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

ClaimResponse.addItem.detail.subDetail.factor
Element IdClaimResponse.addItem.detail.subDetail.factor
Definition

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.

Cardinality0..1
Typedecimal
Requirements

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

Comments

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

ClaimResponse.addItem.detail.subDetail.net
Element IdClaimResponse.addItem.detail.subDetail.net
Definition

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

Cardinality0..1
TypeMoney
Requirements

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

Comments

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

ClaimResponse.addItem.detail.subDetail.noteNumber
Element IdClaimResponse.addItem.detail.subDetail.noteNumber
Definition

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

Cardinality0..*
TypepositiveInt
Requirements

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

ClaimResponse.addItem.detail.subDetail.adjudication
Element IdClaimResponse.addItem.detail.subDetail.adjudication
Definition

The adjudication results.

Cardinality1..*
TypeSee ClaimResponse.item.adjudication
ClaimResponse.adjudication
Element IdClaimResponse.adjudication
Definition

The adjudication results which are presented at the header level rather than at the line-item or add-item levels.

Cardinality0..*
TypeSee ClaimResponse.item.adjudication
Requirements

Some insurers will receive line-items but provide the adjudication only at a summary or header-level.

ClaimResponse.total
Element IdClaimResponse.total
Definition

Categorized monetary totals for the adjudication.

Cardinality0..*
Requirements

To provide the requestor with financial totals by category for the adjudication.

Summarytrue
Comments

Totals for amounts submitted, co-pays, benefits payable etc.

ClaimResponse.total.category
Element IdClaimResponse.total.category
Definition

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.

Cardinality1..1
Terminology BindingAdjudication Value Codes (Example)
TypeCodeableConcept
Requirements

Needed to convey the type of total provided.

Summarytrue
Comments

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

ClaimResponse.total.amount
Element IdClaimResponse.total.amount
Definition

Monetary total amount associated with the category.

Cardinality1..1
TypeMoney
Requirements

Needed to convey the total monetary amount.

Summarytrue
ClaimResponse.payment
Element IdClaimResponse.payment
Definition

Payment details for the adjudication of the claim.

Cardinality0..1
Requirements

Needed to convey references to the financial instrument that has been used if payment has been made.

ClaimResponse.payment.type
Element IdClaimResponse.payment.type
Definition

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

Cardinality1..1
Terminology BindingExample Payment Type Codes (Example)
TypeCodeableConcept
Requirements

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

ClaimResponse.payment.adjustment
Element IdClaimResponse.payment.adjustment
Definition

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

Cardinality0..1
TypeMoney
Requirements

To advise the requestor of adjustments applied to the payment.

Comments

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.

ClaimResponse.payment.adjustmentReason
Element IdClaimResponse.payment.adjustmentReason
Definition

Reason for the payment adjustment.

Cardinality0..1
Terminology BindingPayment Adjustment Reason Codes (Example)
TypeCodeableConcept
Requirements

Needed to clarify the monetary adjustment.

ClaimResponse.payment.date
Element IdClaimResponse.payment.date
Definition

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

Cardinality0..1
Typedate
Requirements

To advise the payee when payment can be expected.

ClaimResponse.payment.amount
Element IdClaimResponse.payment.amount
Definition

Benefits payable less any payment adjustment.

Cardinality1..1
TypeMoney
Requirements

Needed to provide the actual payment amount.

ClaimResponse.payment.identifier
Element IdClaimResponse.payment.identifier
Definition

Issuer's unique identifier for the payment instrument.

NoteThis is a business identifier, not a resource identifier (see discussion)
Cardinality0..1
TypeIdentifier
Requirements

Enable the receiver to reconcile when payment received.

Comments

For example: EFT number or check number.

ClaimResponse.fundsReserve
Element IdClaimResponse.fundsReserve
Definition

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

Cardinality0..1
Terminology BindingFundsReserve (Example)
TypeCodeableConcept
Requirements

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

Comments

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

ClaimResponse.formCode
Element IdClaimResponse.formCode
Definition

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

Cardinality0..1
Terminology BindingForms (Example)
TypeCodeableConcept
Requirements

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

Comments

May be needed to identify specific jurisdictional forms.

ClaimResponse.form
Element IdClaimResponse.form
Definition

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

Cardinality0..1
TypeAttachment
Requirements

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

Comments

Needed to permit insurers to include the actual form.

ClaimResponse.processNote
Element IdClaimResponse.processNote
Definition

A note that describes or explains adjudication results in a human readable form.

Cardinality0..*
Requirements

Provides the insurer specific textual explanations associated with the processing.

ClaimResponse.processNote.number
Element IdClaimResponse.processNote.number
Definition

A number to uniquely identify a note entry.

Cardinality0..1
TypepositiveInt
Requirements

Necessary to provide a mechanism to link from adjudications.

ClaimResponse.processNote.type
Element IdClaimResponse.processNote.type
Definition

The business purpose of the note text.

Cardinality0..1
Terminology BindingNoteType (Required)
Typecode
Requirements

To convey the expectation for when the text is used.

ClaimResponse.processNote.text
Element IdClaimResponse.processNote.text
Definition

The explanation or description associated with the processing.

Cardinality1..1
Typestring
Requirements

Required to provide human readable explanation.

ClaimResponse.processNote.language
Element IdClaimResponse.processNote.language
Definition

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

Cardinality0..1
Terminology BindingCommon Languages (Preferred but limited to All Languages)
TypeCodeableConcept
Requirements

Note text may vary from the resource defined language.

Comments

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

ClaimResponse.communicationRequest
Element IdClaimResponse.communicationRequest
Definition

Request for additional supporting or authorizing information.

Cardinality0..*
TypeReference(CommunicationRequest)
Requirements

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

Comments

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

ClaimResponse.insurance
Element IdClaimResponse.insurance
Definition

Financial instruments for reimbursement for the health care products and services specified on the claim.

Cardinality0..*
Requirements

At least one insurer is required for a claim to be a claim.

Comments

All insurance coverages for the patient which may be applicable for reimbursement, of the products and services listed in the claim, are typically provided in the claim to allow insurers to confirm the ordering of the insurance coverages relative to local 'coordination of benefit' rules. One coverage (and only one) with 'focal=true' is to be used in the adjudication of this claim. Coverages appearing before the focal Coverage in the list, and where 'subrogation=false', should provide a reference to the ClaimResponse containing the adjudication results of the prior claim.

ClaimResponse.insurance.sequence
Element IdClaimResponse.insurance.sequence
Definition

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

Cardinality1..1
TypepositiveInt
Requirements

To maintain order of the coverages.

ClaimResponse.insurance.focal
Element IdClaimResponse.insurance.focal
Definition

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

Cardinality1..1
Typeboolean
Requirements

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

Comments

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.

ClaimResponse.insurance.coverage
Element IdClaimResponse.insurance.coverage
Definition

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.

Cardinality1..1
TypeReference(Coverage)
Requirements

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

ClaimResponse.insurance.businessArrangement
Element IdClaimResponse.insurance.businessArrangement
Definition

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

Cardinality0..1
Typestring
Requirements

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

ClaimResponse.insurance.claimResponse
Element IdClaimResponse.insurance.claimResponse
Definition

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

Cardinality0..1
TypeReference(ClaimResponse)
Requirements

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

Comments

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

ClaimResponse.error
Element IdClaimResponse.error
Definition

Errors encountered during the processing of the adjudication.

Cardinality0..*
Requirements

Need to communicate processing issues to the requestor.

Comments

If the request contains errors then an error element should be provided and no adjudication related sections (item, addItem, or payment) should be present.

ClaimResponse.error.itemSequence
Element IdClaimResponse.error.itemSequence
Definition

The sequence number of the line item submitted which contains the error. This value is omitted when the error occurs outside of the item structure.

Cardinality0..1
TypepositiveInt
Requirements

Provides references to the claim items.

ClaimResponse.error.detailSequence
Element IdClaimResponse.error.detailSequence
Definition

The sequence number of the detail within the line item submitted which contains the error. This value is omitted when the error occurs outside of the item structure.

Cardinality0..1
TypepositiveInt
Requirements

Provides references to the claim details within the claim item.

ClaimResponse.error.subDetailSequence
Element IdClaimResponse.error.subDetailSequence
Definition

The sequence number of the sub-detail within the detail within the line item submitted which contains the error. This value is omitted when the error occurs outside of the item structure.

Cardinality0..1
TypepositiveInt
Requirements

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

ClaimResponse.error.code
Element IdClaimResponse.error.code
Definition

An error code, from a specified code system, which details why the claim could not be adjudicated.

Cardinality1..1
Terminology BindingAdjudicationError (Example)
TypeCodeableConcept
Requirements

Required to convey processing errors.