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13.7 Resource ClaimResponse - Content

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

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

13.7.1 Scope and Usage

The ClaimResponse resource provides application level adjudication results, or an application level error, which are the result of processing a submitted Claim resource where that Claim may be the functional corollary of a Claim, Predetermination or a Preauthorization.This resource is the only appropriate response to a Claim which a processing system recognizes as a Claim resource.

This is the adjudicated response to a Claim, Predetermination or Preauthorization. The strength of the payment aspect of the response is matching to the strength of the original request. For a Claim the adjudication indicates payment which is intended to be made. For Preauthorization no payment will actually be made however funds may be reserved to settle a claim submitted later. For Predetermination no payment will actually be made and no assurance is given that the adjudication of a claim submitted later will match the adjudication provided, for example funds may have been exhausted in the interim. Only an actual claim may be expected to result in actual payment.

The ClaimResponse resource may also be returned with the response for the submission of: Re-adjudication and Reversals.

The ClaimResponse resource is an "event" resource from a FHIR workflow perspective - see Workflow Event.

13.7.1.1 Additional Information

Additional information regarding electronic claims content and usage may be found at:

  • Financial Resource Status Lifecycle: how .status is used in the financial resources.
  • Secondary Use of Resources: how resources such as Claim, ClaimResponse and ExplanationOfBenefit may be used for reporting and data exchange for analytics, not just for eClaims exchange between providers and payors.
  • Subrogation: how eClaims may handle patient insurance coverages when another insurer rather than the provider will settle the claim and potentially recover costs against specified coverages.
  • Coordination of Benefit: how eClaims may handle multiple patient insurance coverages.
  • RealTime Exchange and Obtaining Deferred Responsess: ClaimResponses may be obtained using Polling or FHIR REST (SEARCH).
  • Attachments and Supporting Information: how eClaims may handle the provision of supporting information, whether provided by content or reference, within the eClaim resource when submitted to the payor or later in a resource which refers to the subject eClaim resource. This also includes how payors may request additional supporting information from providers.
  • 3-Tier Line Item Hierarchy: 3-tier hierarchy of Goods, products, and Services, to support simple to complex billing.
  • Tax: Tax handling of Goods, products, and Services.

13.7.2 Boundaries and Relationships

The ClaimResponse resource is used to provide the results of the adjudication and/or authorization of a set of healthcare-related products and services for a patient against the patient's insurance coverages, or to respond with what the adjudication would be for a supplied set of products or services should they be actually supplied to the patient.

The ExplanationOfBenefit resource is for reporting out to patients or transferring data to patient centered applications, such as patient health Record (PHR) application, the ExplanationOfBenefit should be used instead of the Claim and ClaimResponse resources as those resources may contain provider and payer specific information which is not appropriate for sharing with the patient.

When using the resources for reporting and transferring claims data, which may have originated in some standard other than FHIR, the Claim resource is useful if only the request side of the information exchange is of interest. If, however, both the request and the adjudication information is to be reported then the ExplanationOfBenefit should be used instead.

When responding whether the patient's coverage is inforce, whether it is valid at this or a specified date, or returning the benefit details or preauthorization requirements associated with a coverage CoverageEligibilityResponse should be used instead and be the response to a CoverageEligibilityRequest.

The eClaim domain includes a number of related resources
ClaimResponse A payor's adjudication and/or authorization response to the suite of services provided in a Claim. Typically the ClaimResponse references the Claim but does not duplicate the clinical or financial information provided in the claim.
ExplanationOfBenefit This resource combines the information from the Claim and the ClaimResponse, stripping out any provider or payor proprietary information, into a unified information model suitable for use for: patient reporting; transferring information to a Patient Health Record system; and, supporting complete claim and adjudication information exchange with regulatory and analytics organizations and other parts of the provider's organization.
Claim A suite of goods and services and insurances coverages under which adjudication or authorization is requested.
CoverageEligibilityResponse The response to a request to a payor, a CoverageEligibilityRequest, to: ascertain whether a coverage is in-force at the current or at a specified time; list the table of benefits; determine whether coverage is provided for specified categories or specific services; and whether preauthorization is required, and if so what supporting information would be required.

13.7.3 References to this Resource

13.7.4 Resource Content

Structure

NameFlagsCard.TypeDescription & Constraintsdoco
.. 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

... traceNumber 0..* Identifier Number for tracking

... status ?!Σ 1..1 code active | cancelled | draft | entered-in-error
Binding: Financial Resource Status Codes (Required)
... type Σ 1..1 CodeableConcept More granular claim type
Binding: Claim Type Codes (Extensible)
... subType 0..1 CodeableConcept More granular claim type
Binding: Example Claim SubType Codes (Example)
... use Σ 1..1 code claim | preauthorization | predetermination
Binding: 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 0..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
Binding: Claim Processing Codes (Required)
... decision Σ 0..1 CodeableConcept Result of the adjudication
Binding: Claim Adjudication Decision Codes (Example)
... disposition 0..1 string Disposition Message
... preAuthRef 0..1 string Preauthorization reference
... preAuthPeriod 0..1 Period Preauthorization reference effective period
... event 0..* BackboneElement Event information

.... type 1..1 CodeableConcept Specific event
Binding: Dates Type Codes (Example)
.... when[x] 1..1 Occurance date or period
..... whenDateTime dateTime
..... whenPeriod Period
... payeeType 0..1 CodeableConcept Party to be paid any benefits payable
Binding: Claim Payee Type Codes (Example)
... encounter 0..* Reference(Encounter) Encounters associated with the listed treatments

... diagnosisRelatedGroup 0..1 CodeableConcept Package billing code
Binding: Example Diagnosis Related Group Codes (Example)
... item 0..* BackboneElement Adjudication for claim line items

.... itemSequence 1..1 positiveInt Claim item instance identifier
.... traceNumber 0..* Identifier Number for tracking

.... noteNumber 0..* positiveInt Applicable note numbers

.... reviewOutcome 0..1 BackboneElement Adjudication results
..... decision 0..1 CodeableConcept Result of the adjudication
Binding: Claim Adjudication Decision Codes (Example)
..... reason 0..* CodeableConcept Reason for result of the adjudication
Binding: Claim Adjudication Decision Reason Codes (Example)

..... preAuthRef 0..1 string Preauthorization reference
..... preAuthPeriod 0..1 Period Preauthorization reference effective period
.... adjudication 0..* BackboneElement Adjudication details

..... category 1..1 CodeableConcept Type of adjudication information
Binding: Adjudication Value Codes (Example)
..... reason 0..1 CodeableConcept Explanation of adjudication outcome
Binding: Adjudication Reason Codes (Example)
..... amount 0..1 Money Monetary amount
..... quantity 0..1 Quantity Non-monetary value
.... detail 0..* BackboneElement Adjudication for claim details

..... detailSequence 1..1 positiveInt Claim detail instance identifier
..... traceNumber 0..* Identifier Number for tracking

..... noteNumber 0..* positiveInt Applicable note numbers

..... reviewOutcome 0..1 see reviewOutcome Detail level adjudication results
..... adjudication 0..* see adjudication Detail level adjudication details

..... subDetail 0..* BackboneElement Adjudication for claim sub-details

...... subDetailSequence 1..1 positiveInt Claim sub-detail instance identifier
...... traceNumber 0..* Identifier Number for tracking

...... noteNumber 0..* positiveInt Applicable note numbers

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

.... traceNumber 0..* Identifier Number for tracking

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

.... revenue 0..1 CodeableConcept Revenue or cost center code
Binding: Example Revenue Center Codes (Example)
.... productOrService 0..1 CodeableConcept Billing, service, product, or drug code
Binding: USCLS Codes (Example)
.... productOrServiceEnd 0..1 CodeableConcept End 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..* CodeableConcept Service/Product billing modifiers
Binding: Modifier type Codes (Example)

.... programCode 0..* CodeableConcept Program the product or service is provided under
Binding: 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
Binding: 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
.... tax 0..1 Money Total tax
.... net 0..1 Money Total item cost
.... bodySite 0..* BackboneElement Anatomical location

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

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

.... noteNumber 0..* positiveInt Applicable note numbers

.... reviewOutcome 0..1 see reviewOutcome Added items adjudication results
.... adjudication 0..* see adjudication Added items adjudication

.... detail 0..* BackboneElement Insurer added line details

..... traceNumber 0..* Identifier Number for tracking

..... revenue 0..1 CodeableConcept Revenue or cost center code
Binding: Example Revenue Center Codes (Example)
..... productOrService 0..1 CodeableConcept Billing, service, product, or drug code
Binding: USCLS Codes (Example)
..... productOrServiceEnd 0..1 CodeableConcept End of a range of codes
Binding: USCLS Codes (Example)
..... modifier 0..* CodeableConcept Service/Product billing modifiers
Binding: 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
..... tax 0..1 Money Total tax
..... net 0..1 Money Total item cost
..... noteNumber 0..* positiveInt Applicable note numbers

..... reviewOutcome 0..1 see reviewOutcome Added items detail level adjudication results
..... adjudication 0..* see adjudication Added items detail adjudication

..... subDetail 0..* BackboneElement Insurer added line items

...... traceNumber 0..* Identifier Number for tracking

...... revenue 0..1 CodeableConcept Revenue or cost center code
Binding: Example Revenue Center Codes (Example)
...... productOrService 0..1 CodeableConcept Billing, service, product, or drug code
Binding: USCLS Codes (Example)
...... productOrServiceEnd 0..1 CodeableConcept End of a range of codes
Binding: USCLS Codes (Example)
...... modifier 0..* CodeableConcept Service/Product billing modifiers
Binding: 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
...... tax 0..1 Money Total tax
...... net 0..1 Money Total item cost
...... noteNumber 0..* positiveInt Applicable note numbers

...... reviewOutcome 0..1 see reviewOutcome Added items subdetail level adjudication results
...... adjudication 0..* see adjudication Added items subdetail adjudication

... adjudication 0..* see adjudication Header-level adjudication

... total Σ 0..* BackboneElement Adjudication totals

.... category Σ 1..1 CodeableConcept Type of adjudication information
Binding: 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
Binding: Example Payment Type Codes (Example)
.... adjustment 0..1 Money Payment adjustment for non-claim issues
.... adjustmentReason 0..1 CodeableConcept Explanation for the adjustment
Binding: 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
Binding: Funds Reservation Codes (Example)
... formCode 0..1 CodeableConcept Printed form identifier
Binding: Form Codes (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 CodeableConcept Note purpose
Binding: NoteType (Extensible)
.... text 1..1 string Note explanatory text
.... language 0..1 CodeableConcept Language of the text
Binding: All Languages (Required)
Additional BindingsPurpose
Common Languages Starter Set

... 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 Σ 1..1 CodeableConcept Error code detailing processing issues
Binding: Adjudication Error Codes (Example)
.... expression Σ 0..* string FHIRPath of element(s) related to issue


doco Documentation for this format icon

See the Extensions for this resource

 

Additional definitions: Master Definition XML + JSON, XML Schema/Schematron + JSON Schema, ShEx (for Turtle) + see the extensions, the spreadsheet version & the dependency analysis

13.7.4.1 Terminology Bindings

Path ValueSet Type Documentation
ClaimResponse.status FinancialResourceStatusCodes Required

This value set includes Status codes.
ClaimResponse.type ClaimTypeCodes Extensible

This value set includes Claim Type codes.
ClaimResponse.subType ExampleClaimSubTypeCodes Example

This value set includes sample Claim SubType codes which are used to distinguish the claim types for example within type institutional there may be subtypes for emergency services, bed stay and transportation.
ClaimResponse.use Use Required

The purpose of the Claim: predetermination, preauthorization, claim.
ClaimResponse.outcome ClaimProcessingCodes (a valid code from Claim Processing Outcome Codes) Required

This value set includes Claim Processing Outcome codes.
ClaimResponse.decision ClaimAdjudicationDecisionsCodes (a valid code from Claim Adjudication Decision Codes) Example

This value set includes Claim Adjudication Decision codes.
ClaimResponse.event.type DatesTypeCodes (a valid code from Dates Event Type Codes) Example

This value set includes sample Dates Type codes.
ClaimResponse.payeeType ClaimPayeeTypeCodes (a valid code from Payee Type Codes icon) Example

This value set includes sample Payee Type codes.
ClaimResponse.diagnosisRelatedGroup ExampleDiagnosisRelatedGroupCodes Example

This value set includes example Diagnosis Related Group codes.
ClaimResponse.item.reviewOutcome.decision ClaimAdjudicationDecisionsCodes (a valid code from Claim Adjudication Decision Codes) Example

This value set includes Claim Adjudication Decision codes.
ClaimResponse.item.reviewOutcome.reason ClaimAdjudicationDecisionReasonCodes Example

This value set includes example Claim Adjudication Decision Reason codes.
ClaimResponse.item.adjudication.category AdjudicationValueCodes Example

This value set includes a smattering of Adjudication Value codes which includes codes to indicate the amounts eligible under the plan, the amount of benefit, copays etc.
ClaimResponse.item.adjudication.reason AdjudicationReasonCodes Example

This value set includes smattering of Adjudication Reason codes.
ClaimResponse.addItem.revenue ExampleRevenueCenterCodes Example

This value set includes sample Revenue Center codes.
ClaimResponse.addItem.productOrService USCLSCodes Example

This value set includes a smattering of USCLS codes.
ClaimResponse.addItem.productOrServiceEnd USCLSCodes Example

This value set includes a smattering of USCLS codes.
ClaimResponse.addItem.modifier ModifierTypeCodes Example

This value set includes sample Modifier type codes.
ClaimResponse.addItem.programCode ExampleProgramReasonCodes Example

This value set includes sample Program Reason Span codes.
ClaimResponse.addItem.location[x] ExampleServicePlaceCodes Example

This value set includes a smattering of Service Place codes.
ClaimResponse.addItem.bodySite.site OralSiteCodes Example

This value set includes a smattering of FDI oral site codes.
ClaimResponse.addItem.bodySite.subSite SurfaceCodes Example

This value set includes a smattering of FDI tooth surface codes.
ClaimResponse.addItem.detail.revenue ExampleRevenueCenterCodes Example

This value set includes sample Revenue Center codes.
ClaimResponse.addItem.detail.productOrService USCLSCodes Example

This value set includes a smattering of USCLS codes.
ClaimResponse.addItem.detail.productOrServiceEnd USCLSCodes Example

This value set includes a smattering of USCLS codes.
ClaimResponse.addItem.detail.modifier ModifierTypeCodes Example

This value set includes sample Modifier type codes.
ClaimResponse.addItem.detail.subDetail.revenue ExampleRevenueCenterCodes Example

This value set includes sample Revenue Center codes.
ClaimResponse.addItem.detail.subDetail.productOrService USCLSCodes Example

This value set includes a smattering of USCLS codes.
ClaimResponse.addItem.detail.subDetail.productOrServiceEnd USCLSCodes Example

This value set includes a smattering of USCLS codes.
ClaimResponse.addItem.detail.subDetail.modifier ModifierTypeCodes Example

This value set includes sample Modifier type codes.
ClaimResponse.total.category AdjudicationValueCodes Example

This value set includes a smattering of Adjudication Value codes which includes codes to indicate the amounts eligible under the plan, the amount of benefit, copays etc.
ClaimResponse.payment.type ExamplePaymentTypeCodes Example

This value set includes example Payment Type codes.
ClaimResponse.payment.adjustmentReason PaymentAdjustmentReasonCodes Example

This value set includes smattering of Payment Adjustment Reason codes.
ClaimResponse.fundsReserve FundsReservationCodes Example

This value set includes sample funds reservation type codes.
ClaimResponse.formCode FormCodes Example

This value set includes a sample set of Forms codes.
ClaimResponse.processNote.type NoteType Extensible

The presentation types of notes.
ClaimResponse.processNote.language AllLanguages (a valid code from Tags for the Identification of Languages icon) Required

This value set includes all possible codes from BCP-47 (see http://tools.ietf.org/html/bcp47)
  Common Languages starter
ClaimResponse.error.code AdjudicationErrorCodes Example

This value set includes a smattering of adjudication codes.



13.7.5 Additional Information

The information presented in different backbone elements, such as .supportingInfo or .adjudication, has a different context based on the .category code presented in each, for example, adjudication occurrence may represent an amount paid by the patient while another may represent the amount paid to the provider.

Additionally, there are several places in the resource which point to other sections of the resource via the use of a .sequence number in the referred-to element and an .elementSequence in the referring element. Sequence numbers appear in such element as .careTeam referred to by .careTeamSequence, .diagnosis referred to by .diagnosisSequence, .procedure referred to by .procedureSequence, .supportingInfo referred to by .informationSequence and .item referred to by .itemSequence.

The .noteNumber element, which appears at the .item, .detail and .subDetail levels in the .item and .addItem structures, contains a list of numbers which match the value of the .number element in the .processNote structure. The process notes are indivdual chunks of text describing a situation associated with insurer explanation of adjudication results. Rather than repeating the same text in the adjudication of line item or detail, the insurer can provide the text once in the .processNote structure then include the associated number value in the list of .noteNumbers for each of the appropriate line items or details.

13.7.6 Search Parameters

Search parameters for this resource. See also the full list of search parameters for this resource, and check the Extensions registry for search parameters on extensions related to this resource. The common parameters also apply. See Searching for more information about searching in REST, messaging, and services.

Name Type Description Expression In Common
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 65 Resources
insurer reference The organization which generated this resource ClaimResponse.insurer
(Organization)
outcome token The processing outcome ClaimResponse.outcome
patient reference The subject of care ClaimResponse.patient
(Patient)		 65 Resources
payment-date date The expected payment date ClaimResponse.payment.date
request reference The claim reference ClaimResponse.request
(Claim)
requestor reference The Provider of the claim ClaimResponse.requestor
(Practitioner, Organization, PractitionerRole)
status token The status of the ClaimResponse ClaimResponse.status
use token The type of claim ClaimResponse.use