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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.

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.

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.

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.

Structure

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 icon

See the Extensions for this resource

UML Diagram (Legend)

ClaimResponse (DomainResource)A unique identifier assigned to this claim responseidentifier : Identifier [0..*]Trace number for tracking purposes. May be defined at the jurisdiction level or between trading partnerstraceNumber : Identifier [0..*]The status of the resource instance (this element modifies the meaning of other elements)status : code [1..1] « null (Strength=Required)FinancialResourceStatusCodes! »A finer grained suite of claim type codes which may convey additional information such as Inpatient vs Outpatient and/or a specialty servicetype : CodeableConcept [1..1] « null (Strength=Extensible)ClaimTypeCodes+ »A finer grained suite of claim type codes which may convey additional information such as Inpatient vs Outpatient and/or a specialty servicesubType : CodeableConcept [0..1] « null (Strength=Example)ExampleClaimSubTypeCodes?? »A code to indicate whether the nature of the request is: Claim - A request to an Insurer to adjudicate the supplied charges for health care goods and services under the identified policy and to pay the determined Benefit amount, if any; Preauthorization - A request to an Insurer to adjudicate the supplied proposed future charges for health care goods and services under the identified policy and to approve the services and provide the expected benefit amounts and potentially to reserve funds to pay the benefits when Claims for the indicated services are later submitted; or, Pre-determination - A request to an Insurer to adjudicate the supplied 'what if' charges for health care goods and services under the identified policy and report back what the Benefit payable would be had the services actually been provideduse : code [1..1] « null (Strength=Required)Use! »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 soughtpatient : Reference [1..1] « Patient »The date this resource was createdcreated : dateTime [1..1]The party responsible for authorization, adjudication and reimbursementinsurer : Reference [0..1] « Organization »The provider which is responsible for the claim, predetermination or preauthorizationrequestor : Reference [0..1] « Practitioner|PractitionerRole| Organization »Original request resource referencerequest : Reference [0..1] « Claim »The outcome of the claim, predetermination, or preauthorization processingoutcome : code [1..1] « null (Strength=Required)ClaimProcessingCodes! »The result of the claim, predetermination, or preauthorization adjudicationdecision : CodeableConcept [0..1] « null (Strength=Example)ClaimAdjudicationDecisionsCod...?? »A human readable description of the status of the adjudicationdisposition : string [0..1]Reference from the Insurer which is used in later communications which refers to this adjudicationpreAuthRef : string [0..1]The time frame during which this authorization is effectivepreAuthPeriod : Period [0..1]Type of Party to be reimbursed: subscriber, provider, otherpayeeType : CodeableConcept [0..1] « null (Strength=Example)ClaimPayeeTypeCodes?? »Healthcare encounters related to this claimencounter : Reference [0..*] « Encounter »A package billing code or bundle code used to group products and services to a particular health condition (such as heart attack) which is based on a predetermined grouping code systemdiagnosisRelatedGroup : CodeableConcept [0..1] « null (Strength=Example) ExampleDiagnosisRelatedGroupC...?? »A code, used only on a response to a preauthorization, to indicate whether the benefits payable have been reserved and for whomfundsReserve : CodeableConcept [0..1] « null (Strength=Example)FundsReservationCodes?? »A code for the form to be used for printing the contentformCode : CodeableConcept [0..1] « null (Strength=Example)FormCodes?? »The actual form, by reference or inclusion, for printing the content or an EOBform : Attachment [0..1]Request for additional supporting or authorizing informationcommunicationRequest : Reference [0..*] « CommunicationRequest »EventA coded event such as when a service is expected or a card printedtype : CodeableConcept [1..1] « null (Strength=Example)DatesTypeCodes?? »A date or period in the past or future indicating when the event occurred or is expectd to occurwhen[x] : DataType [1..1] « dateTime|Period »ItemA number to uniquely reference the claim item entriesitemSequence : positiveInt [1..1]Trace number for tracking purposes. May be defined at the jurisdiction level or between trading partnerstraceNumber : Identifier [0..*]The numbers associated with notes below which apply to the adjudication of this itemnoteNumber : positiveInt [0..*]ReviewOutcomeThe result of the claim, predetermination, or preauthorization adjudicationdecision : CodeableConcept [0..1] « null (Strength=Example)ClaimAdjudicationDecisionsCod...?? »The reasons for the result of the claim, predetermination, or preauthorization adjudicationreason : CodeableConcept [0..*] « null (Strength=Example)ClaimAdjudicationDecisionReas...?? »Reference from the Insurer which is used in later communications which refers to this adjudicationpreAuthRef : string [0..1]The time frame during which this authorization is effectivepreAuthPeriod : Period [0..1]AdjudicationA 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 itemcategory : CodeableConcept [1..1] « null (Strength=Example)AdjudicationValueCodes?? »A code supporting the understanding of the adjudication result and explaining variance from expected amountreason : CodeableConcept [0..1] « null (Strength=Example)AdjudicationReasonCodes?? »Monetary amount associated with the categoryamount : Money [0..1]A non-monetary value associated with the category. Mutually exclusive to the amount element abovequantity : Quantity [0..1]ItemDetailA number to uniquely reference the claim detail entrydetailSequence : positiveInt [1..1]Trace number for tracking purposes. May be defined at the jurisdiction level or between trading partnerstraceNumber : Identifier [0..*]The numbers associated with notes below which apply to the adjudication of this itemnoteNumber : positiveInt [0..*]SubDetailA number to uniquely reference the claim sub-detail entrysubDetailSequence : positiveInt [1..1]Trace number for tracking purposes. May be defined at the jurisdiction level or between trading partnerstraceNumber : Identifier [0..*]The numbers associated with notes below which apply to the adjudication of this itemnoteNumber : positiveInt [0..*]AddedItemClaim items which this service line is intended to replaceitemSequence : positiveInt [0..*]The sequence number of the details within the claim item which this line is intended to replacedetailSequence : positiveInt [0..*]The sequence number of the sub-details within the details within the claim item which this line is intended to replacesubdetailSequence : positiveInt [0..*]Trace number for tracking purposes. May be defined at the jurisdiction level or between trading partnerstraceNumber : Identifier [0..*]The providers who are authorized for the services rendered to the patientprovider : Reference [0..*] « Practitioner|PractitionerRole| Organization »The type of revenue or cost center providing the product and/or servicerevenue : CodeableConcept [0..1] « null (Strength=Example)ExampleRevenueCenterCodes?? »When the value is a group code then this item collects a set of related item details, otherwise this contains the product, service, drug or other billing code for the item. This element may be the start of a range of .productOrService codes used in conjunction with .productOrServiceEnd or it may be a solo element where .productOrServiceEnd is not usedproductOrService : CodeableConcept [0..1] « null (Strength=Example)USCLSCodes?? »This contains the end of a range of product, service, drug or other billing codes for the item. This element is not used when the .productOrService is a group code. This value may only be present when a .productOfService code has been provided to convey the start of the range. Typically this value may be used only with preauthorizations and not with claimsproductOrServiceEnd : CodeableConcept [0..1] « null (Strength=Example)USCLSCodes?? »Request or Referral for Goods or Service to be renderedrequest : Reference [0..*] « DeviceRequest|MedicationRequest| NutritionOrder|ServiceRequest|SupplyRequest|VisionPrescription »Item typification or modifiers codes to convey additional context for the product or servicemodifier : CodeableConcept [0..*] « null (Strength=Example)ModifierTypeCodes?? »Identifies the program under which this may be recoveredprogramCode : CodeableConcept [0..*] « null (Strength=Example)ExampleProgramReasonCodes?? »The date or dates when the service or product was supplied, performed or completedserviced[x] : DataType [0..1] « date|Period »Where the product or service was providedlocation[x] : DataType [0..1] « CodeableConcept|Address|Reference( Location); null (Strength=Example)ExampleServicePlaceCodes?? »The number of repetitions of a service or productquantity : Quantity(SimpleQuantity) [0..1]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 groupunitPrice : Money [0..1]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 amountfactor : decimal [0..1]The total of taxes applicable for this product or servicetax : Money [0..1]The total amount claimed for the group (if a grouper) or the addItem. Net = unit price * quantity * factornet : Money [0..1]The numbers associated with notes below which apply to the adjudication of this itemnoteNumber : positiveInt [0..*]BodySitePhysical service site on the patient (limb, tooth, etc.)site : CodeableReference [1..*] « BodyStructure; null (Strength=Example)OralSiteCodes?? »A region or surface of the bodySite, e.g. limb region or tooth surface(s)subSite : CodeableConcept [0..*] « null (Strength=Example)SurfaceCodes?? »AddedItemDetailTrace number for tracking purposes. May be defined at the jurisdiction level or between trading partnerstraceNumber : Identifier [0..*]The type of revenue or cost center providing the product and/or servicerevenue : CodeableConcept [0..1] « null (Strength=Example)ExampleRevenueCenterCodes?? »When the value is a group code then this item collects a set of related item details, otherwise this contains the product, service, drug or other billing code for the item. This element may be the start of a range of .productOrService codes used in conjunction with .productOrServiceEnd or it may be a solo element where .productOrServiceEnd is not usedproductOrService : CodeableConcept [0..1] « null (Strength=Example)USCLSCodes?? »This contains the end of a range of product, service, drug or other billing codes for the item. This element is not used when the .productOrService is a group code. This value may only be present when a .productOfService code has been provided to convey the start of the range. Typically this value may be used only with preauthorizations and not with claimsproductOrServiceEnd : CodeableConcept [0..1] « null (Strength=Example)USCLSCodes?? »Item typification or modifiers codes to convey additional context for the product or servicemodifier : CodeableConcept [0..*] « null (Strength=Example)ModifierTypeCodes?? »The number of repetitions of a service or productquantity : Quantity(SimpleQuantity) [0..1]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 groupunitPrice : Money [0..1]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 amountfactor : decimal [0..1]The total of taxes applicable for this product or servicetax : Money [0..1]The total amount claimed for the group (if a grouper) or the addItem.detail. Net = unit price * quantity * factornet : Money [0..1]The numbers associated with notes below which apply to the adjudication of this itemnoteNumber : positiveInt [0..*]AddedItemSubDetailTrace number for tracking purposes. May be defined at the jurisdiction level or between trading partnerstraceNumber : Identifier [0..*]The type of revenue or cost center providing the product and/or servicerevenue : CodeableConcept [0..1] « null (Strength=Example)ExampleRevenueCenterCodes?? »When the value is a group code then this item collects a set of related item details, otherwise this contains the product, service, drug or other billing code for the item. This element may be the start of a range of .productOrService codes used in conjunction with .productOrServiceEnd or it may be a solo element where .productOrServiceEnd is not usedproductOrService : CodeableConcept [0..1] « null (Strength=Example)USCLSCodes?? »This contains the end of a range of product, service, drug or other billing codes for the item. This element is not used when the .productOrService is a group code. This value may only be present when a .productOfService code has been provided to convey the start of the range. Typically this value may be used only with preauthorizations and not with claimsproductOrServiceEnd : CodeableConcept [0..1] « null (Strength=Example)USCLSCodes?? »Item typification or modifiers codes to convey additional context for the product or servicemodifier : CodeableConcept [0..*] « null (Strength=Example)ModifierTypeCodes?? »The number of repetitions of a service or productquantity : Quantity(SimpleQuantity) [0..1]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 groupunitPrice : Money [0..1]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 amountfactor : decimal [0..1]The total of taxes applicable for this product or servicetax : Money [0..1]The total amount claimed for the addItem.detail.subDetail. Net = unit price * quantity * factornet : Money [0..1]The numbers associated with notes below which apply to the adjudication of this itemnoteNumber : positiveInt [0..*]TotalA 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 itemcategory : CodeableConcept [1..1] « null (Strength=Example)AdjudicationValueCodes?? »Monetary total amount associated with the categoryamount : Money [1..1]PaymentWhether this represents partial or complete payment of the benefits payabletype : CodeableConcept [1..1] « null (Strength=Example)ExamplePaymentTypeCodes?? »Total amount of all adjustments to this payment included in this transaction which are not related to this claim's adjudicationadjustment : Money [0..1]Reason for the payment adjustmentadjustmentReason : CodeableConcept [0..1] « null (Strength=Example) PaymentAdjustmentReasonCodes?? »Estimated date the payment will be issued or the actual issue date of paymentdate : date [0..1]Benefits payable less any payment adjustmentamount : Money [1..1]Issuer's unique identifier for the payment instrumentidentifier : Identifier [0..1]NoteA number to uniquely identify a note entrynumber : positiveInt [0..1]The business purpose of the note texttype : CodeableConcept [0..1] « null (Strength=Extensible)NoteType+ »The explanation or description associated with the processingtext : string [1..1]A code to define the language used in the text of the notelanguage : CodeableConcept [0..1] « null (Strength=Required)AllLanguages! »InsuranceA number to uniquely identify insurance entries and provide a sequence of coverages to convey coordination of benefit ordersequence : positiveInt [1..1]A flag to indicate that this Coverage is to be used for adjudication of this claim when set to truefocal : boolean [1..1]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 systemcoverage : Reference [1..1] « Coverage »A business agreement number established between the provider and the insurer for special business processing purposesbusinessArrangement : string [0..1]The result of the adjudication of the line items for the Coverage specified in this insuranceclaimResponse : Reference [0..1] « ClaimResponse »ErrorThe sequence number of the line item submitted which contains the error. This value is omitted when the error occurs outside of the item structureitemSequence : positiveInt [0..1]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 structuredetailSequence : positiveInt [0..1]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 structuresubDetailSequence : positiveInt [0..1]An error code, from a specified code system, which details why the claim could not be adjudicatedcode : CodeableConcept [1..1] « null (Strength=Example)AdjudicationErrorCodes?? »A [simple subset of FHIRPath](fhirpath.html#simple) limited to element names, repetition indicators and the default child accessor that identifies one of the elements in the resource that caused this issue to be raisedexpression : string [0..*]Information code for an event with a corresponding date or periodevent[0..*]The high-level results of the adjudication if adjudication has been performedreviewOutcome[0..1]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 itemadjudication[0..*]The high-level results of the adjudication if adjudication has been performedreviewOutcome[0..1]The adjudication resultsadjudication[0..*]The high-level results of the adjudication if adjudication has been performedreviewOutcome[0..1]The adjudication resultsadjudication[0..*]A sub-detail adjudication of a simple product or servicesubDetail[0..*]A claim detail. Either a simple (a product or service) or a 'group' of sub-details which are simple itemsdetail[0..*]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-detailsitem[0..*]Physical location where the service is performed or appliesbodySite[0..*]The high-level results of the adjudication if adjudication has been performedreviewOutcome[0..1]The adjudication resultsadjudication[0..*]The high-level results of the adjudication if adjudication has been performedreviewOutcome[0..1]The adjudication resultsadjudication[0..*]The high-level results of the adjudication if adjudication has been performedreviewOutcome[0..1]The adjudication resultsadjudication[0..*]The third-tier service adjudications for payor added servicessubDetail[0..*]The second-tier service adjudications for payor added servicesdetail[0..*]The first-tier service adjudications for payor added product or service linesaddItem[0..*]The adjudication results which are presented at the header level rather than at the line-item or add-item levelsadjudication[0..*]Categorized monetary totals for the adjudicationtotal[0..*]Payment details for the adjudication of the claimpayment[0..1]A note that describes or explains adjudication results in a human readable formprocessNote[0..*]Financial instruments for reimbursement for the health care products and services specified on the claiminsurance[0..*]Errors encountered during the processing of the adjudicationerror[0..*]

XML Template

<ClaimResponse xmlns="http://hl7.org/fhir"> doco
 <!-- from Resource: id, meta, implicitRules, and language -->
 <!-- from DomainResource: text, contained, extension, and modifierExtension -->
 <identifier><!-- 0..* Identifier Business Identifier for a claim response --></identifier>
 <traceNumber><!-- 0..* Identifier Number for tracking --></traceNumber>
 <status value="[code]"/><!-- 1..1 active | cancelled | draft | entered-in-error -->
 <type><!-- 1..1 CodeableConcept More granular claim type --></type>
 <subType><!-- 0..1 CodeableConcept More granular claim type --></subType>
 <use value="[code]"/><!-- 1..1 claim | preauthorization | predetermination -->
 <patient><!-- 1..1 Reference(Patient) The recipient of the products and services --></patient>
 <created value="[dateTime]"/><!-- 1..1 Response creation date -->
 <insurer><!-- 0..1 Reference(Organization) Party responsible for reimbursement --></insurer>
 <requestor><!-- 0..1 Reference(Organization|Practitioner|PractitionerRole) Party responsible for the claim --></requestor>
 <request><!-- 0..1 Reference(Claim) Id of resource triggering adjudication --></request>
 <outcome value="[code]"/><!-- 1..1 queued | complete | error | partial -->
 <decision><!-- 0..1 CodeableConcept Result of the adjudication --></decision>
 <disposition value="[string]"/><!-- 0..1 Disposition Message -->
 <preAuthRef value="[string]"/><!-- 0..1 Preauthorization reference -->
 <preAuthPeriod><!-- 0..1 Period Preauthorization reference effective period --></preAuthPeriod>
 <event>  <!-- 0..* Event information -->
  <type><!-- 1..1 CodeableConcept Specific event --></type>
  <when[x]><!-- 1..1 dateTime|Period Occurance date or period --></when[x]>
 </event>
 <payeeType><!-- 0..1 CodeableConcept Party to be paid any benefits payable --></payeeType>
 <encounter><!-- 0..* Reference(Encounter) Encounters associated with the listed treatments --></encounter>
 <diagnosisRelatedGroup><!-- 0..1 CodeableConcept Package billing code --></diagnosisRelatedGroup>
 <item>  <!-- 0..* Adjudication for claim line items -->
  <itemSequence value="[positiveInt]"/><!-- 1..1 Claim item instance identifier -->
  <traceNumber><!-- 0..* Identifier Number for tracking --></traceNumber>
  <noteNumber value="[positiveInt]"/><!-- 0..* Applicable note numbers -->
  <reviewOutcome>  <!-- 0..1 Adjudication results -->
   <decision><!-- 0..1 CodeableConcept Result of the adjudication --></decision>
   <reason><!-- 0..* CodeableConcept Reason for result of the adjudication --></reason>
   <preAuthRef value="[string]"/><!-- 0..1 Preauthorization reference -->
   <preAuthPeriod><!-- 0..1 Period Preauthorization reference effective period --></preAuthPeriod>
  </reviewOutcome>
  <adjudication>  <!-- 0..* Adjudication details -->
   <category><!-- 1..1 CodeableConcept Type of adjudication information --></category>
   <reason><!-- 0..1 CodeableConcept Explanation of adjudication outcome --></reason>
   <amount><!-- 0..1 Money Monetary amount --></amount>
   <quantity><!-- 0..1 Quantity Non-monetary value --></quantity>
  </adjudication>
  <detail>  <!-- 0..* Adjudication for claim details -->
   <detailSequence value="[positiveInt]"/><!-- 1..1 Claim detail instance identifier -->
   <traceNumber><!-- 0..* Identifier Number for tracking --></traceNumber>
   <noteNumber value="[positiveInt]"/><!-- 0..* Applicable note numbers -->
   <reviewOutcome><!-- 0..1 Content as for ClaimResponse.item.reviewOutcome Detail level adjudication results --></reviewOutcome>
   <adjudication><!-- 0..* Content as for ClaimResponse.item.adjudication Detail level adjudication details --></adjudication>
   <subDetail>  <!-- 0..* Adjudication for claim sub-details -->
    <subDetailSequence value="[positiveInt]"/><!-- 1..1 Claim sub-detail instance identifier -->
    <traceNumber><!-- 0..* Identifier Number for tracking --></traceNumber>
    <noteNumber value="[positiveInt]"/><!-- 0..* Applicable note numbers -->
    <reviewOutcome><!-- 0..1 Content as for ClaimResponse.item.reviewOutcome Subdetail level adjudication results --></reviewOutcome>
    <adjudication><!-- 0..* Content as for ClaimResponse.item.adjudication Subdetail level adjudication details --></adjudication>
   </subDetail>
  </detail>
 </item>
 <addItem>  <!-- 0..* Insurer added line items -->
  <itemSequence value="[positiveInt]"/><!-- 0..* Item sequence number -->
  <detailSequence value="[positiveInt]"/><!-- 0..* Detail sequence number -->
  <subdetailSequence value="[positiveInt]"/><!-- 0..* Subdetail sequence number -->
  <traceNumber><!-- 0..* Identifier Number for tracking --></traceNumber>
  <provider><!-- 0..* Reference(Organization|Practitioner|PractitionerRole) Authorized providers --></provider>
  <revenue><!-- 0..1 CodeableConcept Revenue or cost center code --></revenue>
  <productOrService><!-- 0..1 CodeableConcept Billing, service, product, or drug code --></productOrService>
  <productOrServiceEnd><!-- 0..1 CodeableConcept End of a range of codes --></productOrServiceEnd>
  <request><!-- 0..* Reference(DeviceRequest|MedicationRequest|NutritionOrder|
    ServiceRequest|SupplyRequest|VisionPrescription) Request or Referral for Service --></request>
  <modifier><!-- 0..* CodeableConcept Service/Product billing modifiers --></modifier>
  <programCode><!-- 0..* CodeableConcept Program the product or service is provided under --></programCode>
  <serviced[x]><!-- 0..1 date|Period Date or dates of service or product delivery --></serviced[x]>
  <location[x]><!-- 0..1 CodeableConcept|Address|Reference(Location) Place of service or where product was supplied --></location[x]>
  <quantity><!-- 0..1 Quantity(SimpleQuantity) Count of products or services --></quantity>
  <unitPrice><!-- 0..1 Money Fee, charge or cost per item --></unitPrice>
  <factor value="[decimal]"/><!-- 0..1 Price scaling factor -->
  <tax><!-- 0..1 Money Total tax --></tax>
  <net><!-- 0..1 Money Total item cost --></net>
  <bodySite>  <!-- 0..* Anatomical location -->
   <site><!-- 1..* CodeableReference(BodyStructure) Location --></site>
   <subSite><!-- 0..* CodeableConcept Sub-location --></subSite>
  </bodySite>
  <noteNumber value="[positiveInt]"/><!-- 0..* Applicable note numbers -->
  <reviewOutcome><!-- 0..1 Content as for ClaimResponse.item.reviewOutcome Added items adjudication results --></reviewOutcome>
  <adjudication><!-- 0..* Content as for ClaimResponse.item.adjudication Added items adjudication --></adjudication>
  <detail>  <!-- 0..* Insurer added line details -->
   <traceNumber><!-- 0..* Identifier Number for tracking --></traceNumber>
   <revenue><!-- 0..1 CodeableConcept Revenue or cost center code --></revenue>
   <productOrService><!-- 0..1 CodeableConcept Billing, service, product, or drug code --></productOrService>
   <productOrServiceEnd><!-- 0..1 CodeableConcept End of a range of codes --></productOrServiceEnd>
   <modifier><!-- 0..* CodeableConcept Service/Product billing modifiers --></modifier>
   <quantity><!-- 0..1 Quantity(SimpleQuantity) Count of products or services --></quantity>
   <unitPrice><!-- 0..1 Money Fee, charge or cost per item --></unitPrice>
   <factor value="[decimal]"/><!-- 0..1 Price scaling factor -->
   <tax><!-- 0..1 Money Total tax --></tax>
   <net><!-- 0..1 Money Total item cost --></net>
   <noteNumber value="[positiveInt]"/><!-- 0..* Applicable note numbers -->
   <reviewOutcome><!-- 0..1 Content as for ClaimResponse.item.reviewOutcome Added items detail level adjudication results --></reviewOutcome>
   <adjudication><!-- 0..* Content as for ClaimResponse.item.adjudication Added items detail adjudication --></adjudication>
   <subDetail>  <!-- 0..* Insurer added line items -->
    <traceNumber><!-- 0..* Identifier Number for tracking --></traceNumber>
    <revenue><!-- 0..1 CodeableConcept Revenue or cost center code --></revenue>
    <productOrService><!-- 0..1 CodeableConcept Billing, service, product, or drug code --></productOrService>
    <productOrServiceEnd><!-- 0..1 CodeableConcept End of a range of codes --></productOrServiceEnd>
    <modifier><!-- 0..* CodeableConcept Service/Product billing modifiers --></modifier>
    <quantity><!-- 0..1 Quantity(SimpleQuantity) Count of products or services --></quantity>
    <unitPrice><!-- 0..1 Money Fee, charge or cost per item --></unitPrice>
    <factor value="[decimal]"/><!-- 0..1 Price scaling factor -->
    <tax><!-- 0..1 Money Total tax --></tax>
    <net><!-- 0..1 Money Total item cost --></net>
    <noteNumber value="[positiveInt]"/><!-- 0..* Applicable note numbers -->
    <reviewOutcome><!-- 0..1 Content as for ClaimResponse.item.reviewOutcome Added items subdetail level adjudication results --></reviewOutcome>
    <adjudication><!-- 0..* Content as for ClaimResponse.item.adjudication Added items subdetail adjudication --></adjudication>
   </subDetail>
  </detail>
 </addItem>
 <adjudication><!-- 0..* Content as for ClaimResponse.item.adjudication Header-level adjudication --></adjudication>
 <total>  <!-- 0..* Adjudication totals -->
  <category><!-- 1..1 CodeableConcept Type of adjudication information --></category>
  <amount><!-- 1..1 Money Financial total for the category --></amount>
 </total>
 <payment>  <!-- 0..1 Payment Details -->
  <type><!-- 1..1 CodeableConcept Partial or complete payment --></type>
  <adjustment><!-- 0..1 Money Payment adjustment for non-claim issues --></adjustment>
  <adjustmentReason><!-- 0..1 CodeableConcept Explanation for the adjustment --></adjustmentReason>
  <date value="[date]"/><!-- 0..1 Expected date of payment -->
  <amount><!-- 1..1 Money Payable amount after adjustment --></amount>
  <identifier><!-- 0..1 Identifier Business identifier for the payment --></identifier>
 </payment>
 <fundsReserve><!-- 0..1 CodeableConcept Funds reserved status --></fundsReserve>
 <formCode><!-- 0..1 CodeableConcept Printed form identifier --></formCode>
 <form><!-- 0..1 Attachment Printed reference or actual form --></form>
 <processNote>  <!-- 0..* Note concerning adjudication -->
  <number value="[positiveInt]"/><!-- 0..1 Note instance identifier -->
  <type><!-- 0..1 CodeableConcept Note purpose --></type>
  <text value="[string]"/><!-- 1..1 Note explanatory text -->
  <language><!-- 0..1 CodeableConcept Language of the text --></language>
 </processNote>
 <communicationRequest><!-- 0..* Reference(CommunicationRequest) Request for additional information --></communicationRequest>
 <insurance>  <!-- 0..* Patient insurance information -->
  <sequence value="[positiveInt]"/><!-- 1..1 Insurance instance identifier -->
  <focal value="[boolean]"/><!-- 1..1 Coverage to be used for adjudication -->
  <coverage><!-- 1..1 Reference(Coverage) Insurance information --></coverage>
  <businessArrangement value="[string]"/><!-- 0..1 Additional provider contract number -->
  <claimResponse><!-- 0..1 Reference(ClaimResponse) Adjudication results --></claimResponse>
 </insurance>
 <error>  <!-- 0..* Processing errors -->
  <itemSequence value="[positiveInt]"/><!-- 0..1 Item sequence number -->
  <detailSequence value="[positiveInt]"/><!-- 0..1 Detail sequence number -->
  <subDetailSequence value="[positiveInt]"/><!-- 0..1 Subdetail sequence number -->
  <code><!-- 1..1 CodeableConcept Error code detailing processing issues --></code>
  <expression value="[string]"/><!-- 0..* FHIRPath of element(s) related to issue -->
 </error>
</ClaimResponse>

JSON Template

{doco
  "resourceType" : "ClaimResponse",
  // from Resource: id, meta, implicitRules, and language
  // from DomainResource: text, contained, extension, and modifierExtension
  "identifier" : [{ Identifier }], // Business Identifier for a claim response
  "traceNumber" : [{ Identifier }], // Number for tracking
  "status" : "<code>", // R!  active | cancelled | draft | entered-in-error
  "type" : { CodeableConcept }, // R!  More granular claim type
  "subType" : { CodeableConcept }, // More granular claim type
  "use" : "<code>", // R!  claim | preauthorization | predetermination
  "patient" : { Reference(Patient) }, // R!  The recipient of the products and services
  "created" : "<dateTime>", // R!  Response creation date
  "insurer" : { Reference(Organization) }, // Party responsible for reimbursement
  "requestor" : { Reference(Organization|Practitioner|PractitionerRole) }, // Party responsible for the claim
  "request" : { Reference(Claim) }, // Id of resource triggering adjudication
  "outcome" : "<code>", // R!  queued | complete | error | partial
  "decision" : { CodeableConcept }, // Result of the adjudication
  "disposition" : "<string>", // Disposition Message
  "preAuthRef" : "<string>", // Preauthorization reference
  "preAuthPeriod" : { Period }, // Preauthorization reference effective period
  "event" : [{ // Event information
    "type" : { CodeableConcept }, // R!  Specific event
    // when[x]: Occurance date or period. One of these 2:
    "whenDateTime" : "<dateTime>",
    "whenPeriod" : { Period }
  }],
  "payeeType" : { CodeableConcept }, // Party to be paid any benefits payable
  "encounter" : [{ Reference(Encounter) }], // Encounters associated with the listed treatments
  "diagnosisRelatedGroup" : { CodeableConcept }, // Package billing code
  "item" : [{ // Adjudication for claim line items
    "itemSequence" : "<positiveInt>", // R!  Claim item instance identifier
    "traceNumber" : [{ Identifier }], // Number for tracking
    "noteNumber" : ["<positiveInt>"], // Applicable note numbers
    "reviewOutcome" : { // Adjudication results
      "decision" : { CodeableConcept }, // Result of the adjudication
      "reason" : [{ CodeableConcept }], // Reason for result of the adjudication
      "preAuthRef" : "<string>", // Preauthorization reference
      "preAuthPeriod" : { Period } // Preauthorization reference effective period
    },
    "adjudication" : [{ // Adjudication details
      "category" : { CodeableConcept }, // R!  Type of adjudication information
      "reason" : { CodeableConcept }, // Explanation of adjudication outcome
      "amount" : { Money }, // Monetary amount
      "quantity" : { Quantity } // Non-monetary value
    }],
    "detail" : [{ // Adjudication for claim details
      "detailSequence" : "<positiveInt>", // R!  Claim detail instance identifier
      "traceNumber" : [{ Identifier }], // Number for tracking
      "noteNumber" : ["<positiveInt>"], // Applicable note numbers
      "reviewOutcome" : { Content as for ClaimResponse.item.reviewOutcome }, // Detail level adjudication results
      "adjudication" : [{ Content as for ClaimResponse.item.adjudication }], // Detail level adjudication details
      "subDetail" : [{ // Adjudication for claim sub-details
        "subDetailSequence" : "<positiveInt>", // R!  Claim sub-detail instance identifier
        "traceNumber" : [{ Identifier }], // Number for tracking
        "noteNumber" : ["<positiveInt>"], // Applicable note numbers
        "reviewOutcome" : { Content as for ClaimResponse.item.reviewOutcome }, // Subdetail level adjudication results
        "adjudication" : [{ Content as for ClaimResponse.item.adjudication }] // Subdetail level adjudication details
      }]
    }]
  }],
  "addItem" : [{ // Insurer added line items
    "itemSequence" : ["<positiveInt>"], // Item sequence number
    "detailSequence" : ["<positiveInt>"], // Detail sequence number
    "subdetailSequence" : ["<positiveInt>"], // Subdetail sequence number
    "traceNumber" : [{ Identifier }], // Number for tracking
    "provider" : [{ Reference(Organization|Practitioner|PractitionerRole) }], // Authorized providers
    "revenue" : { CodeableConcept }, // Revenue or cost center code
    "productOrService" : { CodeableConcept }, // Billing, service, product, or drug code
    "productOrServiceEnd" : { CodeableConcept }, // End of a range of codes
    "request" : [{ Reference(DeviceRequest|MedicationRequest|NutritionOrder|
    ServiceRequest|SupplyRequest|VisionPrescription) }], // Request or Referral for Service
    "modifier" : [{ CodeableConcept }], // Service/Product billing modifiers
    "programCode" : [{ CodeableConcept }], // Program the product or service is provided under
    // serviced[x]: Date or dates of service or product delivery. One of these 2:
    "servicedDate" : "<date>",
    "servicedPeriod" : { Period },
    // location[x]: Place of service or where product was supplied. One of these 3:
    "locationCodeableConcept" : { CodeableConcept },
    "locationAddress" : { Address },
    "locationReference" : { Reference(Location) },
    "quantity" : { Quantity(SimpleQuantity) }, // Count of products or services
    "unitPrice" : { Money }, // Fee, charge or cost per item
    "factor" : <decimal>, // Price scaling factor
    "tax" : { Money }, // Total tax
    "net" : { Money }, // Total item cost
    "bodySite" : [{ // Anatomical location
      "site" : [{ CodeableReference(BodyStructure) }], // R!  Location
      "subSite" : [{ CodeableConcept }] // Sub-location
    }],
    "noteNumber" : ["<positiveInt>"], // Applicable note numbers
    "reviewOutcome" : { Content as for ClaimResponse.item.reviewOutcome }, // Added items adjudication results
    "adjudication" : [{ Content as for ClaimResponse.item.adjudication }], // Added items adjudication
    "detail" : [{ // Insurer added line details
      "traceNumber" : [{ Identifier }], // Number for tracking
      "revenue" : { CodeableConcept }, // Revenue or cost center code
      "productOrService" : { CodeableConcept }, // Billing, service, product, or drug code
      "productOrServiceEnd" : { CodeableConcept }, // End of a range of codes
      "modifier" : [{ CodeableConcept }], // Service/Product billing modifiers
      "quantity" : { Quantity(SimpleQuantity) }, // Count of products or services
      "unitPrice" : { Money }, // Fee, charge or cost per item
      "factor" : <decimal>, // Price scaling factor
      "tax" : { Money }, // Total tax
      "net" : { Money }, // Total item cost
      "noteNumber" : ["<positiveInt>"], // Applicable note numbers
      "reviewOutcome" : { Content as for ClaimResponse.item.reviewOutcome }, // Added items detail level adjudication results
      "adjudication" : [{ Content as for ClaimResponse.item.adjudication }], // Added items detail adjudication
      "subDetail" : [{ // Insurer added line items
        "traceNumber" : [{ Identifier }], // Number for tracking
        "revenue" : { CodeableConcept }, // Revenue or cost center code
        "productOrService" : { CodeableConcept }, // Billing, service, product, or drug code
        "productOrServiceEnd" : { CodeableConcept }, // End of a range of codes
        "modifier" : [{ CodeableConcept }], // Service/Product billing modifiers
        "quantity" : { Quantity(SimpleQuantity) }, // Count of products or services
        "unitPrice" : { Money }, // Fee, charge or cost per item
        "factor" : <decimal>, // Price scaling factor
        "tax" : { Money }, // Total tax
        "net" : { Money }, // Total item cost
        "noteNumber" : ["<positiveInt>"], // Applicable note numbers
        "reviewOutcome" : { Content as for ClaimResponse.item.reviewOutcome }, // Added items subdetail level adjudication results
        "adjudication" : [{ Content as for ClaimResponse.item.adjudication }] // Added items subdetail adjudication
      }]
    }]
  }],
  "adjudication" : [{ Content as for ClaimResponse.item.adjudication }], // Header-level adjudication
  "total" : [{ // Adjudication totals
    "category" : { CodeableConcept }, // R!  Type of adjudication information
    "amount" : { Money } // R!  Financial total for the category
  }],
  "payment" : { // Payment Details
    "type" : { CodeableConcept }, // R!  Partial or complete payment
    "adjustment" : { Money }, // Payment adjustment for non-claim issues
    "adjustmentReason" : { CodeableConcept }, // Explanation for the adjustment
    "date" : "<date>", // Expected date of payment
    "amount" : { Money }, // R!  Payable amount after adjustment
    "identifier" : { Identifier } // Business identifier for the payment
  },
  "fundsReserve" : { CodeableConcept }, // Funds reserved status
  "formCode" : { CodeableConcept }, // Printed form identifier
  "form" : { Attachment }, // Printed reference or actual form
  "processNote" : [{ // Note concerning adjudication
    "number" : "<positiveInt>", // Note instance identifier
    "type" : { CodeableConcept }, // Note purpose
    "text" : "<string>", // R!  Note explanatory text
    "language" : { CodeableConcept } // Language of the text
  }],
  "communicationRequest" : [{ Reference(CommunicationRequest) }], // Request for additional information
  "insurance" : [{ // Patient insurance information
    "sequence" : "<positiveInt>", // R!  Insurance instance identifier
    "focal" : <boolean>, // R!  Coverage to be used for adjudication
    "coverage" : { Reference(Coverage) }, // R!  Insurance information
    "businessArrangement" : "<string>", // Additional provider contract number
    "claimResponse" : { Reference(ClaimResponse) } // Adjudication results
  }],
  "error" : [{ // Processing errors
    "itemSequence" : "<positiveInt>", // Item sequence number
    "detailSequence" : "<positiveInt>", // Detail sequence number
    "subDetailSequence" : "<positiveInt>", // Subdetail sequence number
    "code" : { CodeableConcept }, // R!  Error code detailing processing issues
    "expression" : ["<string>"] // FHIRPath of element(s) related to issue
  }]
}

Turtle Template

@prefix fhir: <http://hl7.org/fhir/> .doco


[ a fhir:ClaimResponse;
  fhir:nodeRole fhir:treeRoot; # if this is the parser root

  # from Resource: .id, .meta, .implicitRules, and .language
  # from DomainResource: .text, .contained, .extension, and .modifierExtension
  fhir:identifier  ( [ Identifier ] ... ) ; # 0..* Business Identifier for a claim response
  fhir:traceNumber  ( [ Identifier ] ... ) ; # 0..* Number for tracking
  fhir:status [ code ] ; # 1..1 active | cancelled | draft | entered-in-error
  fhir:type [ CodeableConcept ] ; # 1..1 More granular claim type
  fhir:subType [ CodeableConcept ] ; # 0..1 More granular claim type
  fhir:use [ code ] ; # 1..1 claim | preauthorization | predetermination
  fhir:patient [ Reference(Patient) ] ; # 1..1 The recipient of the products and services
  fhir:created [ dateTime ] ; # 1..1 Response creation date
  fhir:insurer [ Reference(Organization) ] ; # 0..1 Party responsible for reimbursement
  fhir:requestor [ Reference(Organization|Practitioner|PractitionerRole) ] ; # 0..1 Party responsible for the claim
  fhir:request [ Reference(Claim) ] ; # 0..1 Id of resource triggering adjudication
  fhir:outcome [ code ] ; # 1..1 queued | complete | error | partial
  fhir:decision [ CodeableConcept ] ; # 0..1 Result of the adjudication
  fhir:disposition [ string ] ; # 0..1 Disposition Message
  fhir:preAuthRef [ string ] ; # 0..1 Preauthorization reference
  fhir:preAuthPeriod [ Period ] ; # 0..1 Preauthorization reference effective period
  fhir:event ( [ # 0..* Event information
    fhir:type [ CodeableConcept ] ; # 1..1 Specific event
    # when[x] : 1..1 Occurance date or period. One of these 2
      fhir:when [  a fhir:dateTime ; dateTime ]
      fhir:when [  a fhir:Period ; Period ]
  ] ... ) ;
  fhir:payeeType [ CodeableConcept ] ; # 0..1 Party to be paid any benefits payable
  fhir:encounter  ( [ Reference(Encounter) ] ... ) ; # 0..* Encounters associated with the listed treatments
  fhir:diagnosisRelatedGroup [ CodeableConcept ] ; # 0..1 Package billing code
  fhir:item ( [ # 0..* Adjudication for claim line items
    fhir:itemSequence [ positiveInt ] ; # 1..1 Claim item instance identifier
    fhir:traceNumber  ( [ Identifier ] ... ) ; # 0..* Number for tracking
    fhir:noteNumber  ( [ positiveInt ] ... ) ; # 0..* Applicable note numbers
    fhir:reviewOutcome [ # 0..1 Adjudication results
      fhir:decision [ CodeableConcept ] ; # 0..1 Result of the adjudication
      fhir:reason  ( [ CodeableConcept ] ... ) ; # 0..* Reason for result of the adjudication
      fhir:preAuthRef [ string ] ; # 0..1 Preauthorization reference
      fhir:preAuthPeriod [ Period ] ; # 0..1 Preauthorization reference effective period
    ] ;
    fhir:adjudication ( [ # 0..* Adjudication details
      fhir:category [ CodeableConcept ] ; # 1..1 Type of adjudication information
      fhir:reason [ CodeableConcept ] ; # 0..1 Explanation of adjudication outcome
      fhir:amount [ Money ] ; # 0..1 Monetary amount
      fhir:quantity [ Quantity ] ; # 0..1 Non-monetary value
    ] ... ) ;
    fhir:detail ( [ # 0..* Adjudication for claim details
      fhir:detailSequence [ positiveInt ] ; # 1..1 Claim detail instance identifier
      fhir:traceNumber  ( [ Identifier ] ... ) ; # 0..* Number for tracking
      fhir:noteNumber  ( [ positiveInt ] ... ) ; # 0..* Applicable note numbers
      fhir:reviewOutcome [ See ClaimResponse.item.reviewOutcome ] ; # 0..1 Detail level adjudication results
      fhir:adjudication  ( [ See ClaimResponse.item.adjudication ] ... ) ; # 0..* Detail level adjudication details
      fhir:subDetail ( [ # 0..* Adjudication for claim sub-details
        fhir:subDetailSequence [ positiveInt ] ; # 1..1 Claim sub-detail instance identifier
        fhir:traceNumber  ( [ Identifier ] ... ) ; # 0..* Number for tracking
        fhir:noteNumber  ( [ positiveInt ] ... ) ; # 0..* Applicable note numbers
        fhir:reviewOutcome [ See ClaimResponse.item.reviewOutcome ] ; # 0..1 Subdetail level adjudication results
        fhir:adjudication  ( [ See ClaimResponse.item.adjudication ] ... ) ; # 0..* Subdetail level adjudication details
      ] ... ) ;
    ] ... ) ;
  ] ... ) ;
  fhir:addItem ( [ # 0..* Insurer added line items
    fhir:itemSequence  ( [ positiveInt ] ... ) ; # 0..* Item sequence number
    fhir:detailSequence  ( [ positiveInt ] ... ) ; # 0..* Detail sequence number
    fhir:subdetailSequence  ( [ positiveInt ] ... ) ; # 0..* Subdetail sequence number
    fhir:traceNumber  ( [ Identifier ] ... ) ; # 0..* Number for tracking
    fhir:provider  ( [ Reference(Organization|Practitioner|PractitionerRole) ] ... ) ; # 0..* Authorized providers
    fhir:revenue [ CodeableConcept ] ; # 0..1 Revenue or cost center code
    fhir:productOrService [ CodeableConcept ] ; # 0..1 Billing, service, product, or drug code
    fhir:productOrServiceEnd [ CodeableConcept ] ; # 0..1 End of a range of codes
    fhir:request  ( [ Reference(DeviceRequest|MedicationRequest|NutritionOrder|ServiceRequest|SupplyRequest|
  VisionPrescription) ] ... ) ; # 0..* Request or Referral for Service
    fhir:modifier  ( [ CodeableConcept ] ... ) ; # 0..* Service/Product billing modifiers
    fhir:programCode  ( [ CodeableConcept ] ... ) ; # 0..* Program the product or service is provided under
    # serviced[x] : 0..1 Date or dates of service or product delivery. One of these 2
      fhir:serviced [  a fhir:date ; date ]
      fhir:serviced [  a fhir:Period ; Period ]
    # location[x] : 0..1 Place of service or where product was supplied. One of these 3
      fhir:location [  a fhir:CodeableConcept ; CodeableConcept ]
      fhir:location [  a fhir:Address ; Address ]
      fhir:location [  a fhir:Reference ; Reference(Location) ]
    fhir:quantity [ Quantity(SimpleQuantity) ] ; # 0..1 Count of products or services
    fhir:unitPrice [ Money ] ; # 0..1 Fee, charge or cost per item
    fhir:factor [ decimal ] ; # 0..1 Price scaling factor
    fhir:tax [ Money ] ; # 0..1 Total tax
    fhir:net [ Money ] ; # 0..1 Total item cost
    fhir:bodySite ( [ # 0..* Anatomical location
      fhir:site  ( [ CodeableReference(BodyStructure) ] ... ) ; # 1..* Location
      fhir:subSite  ( [ CodeableConcept ] ... ) ; # 0..* Sub-location
    ] ... ) ;
    fhir:noteNumber  ( [ positiveInt ] ... ) ; # 0..* Applicable note numbers
    fhir:reviewOutcome [ See ClaimResponse.item.reviewOutcome ] ; # 0..1 Added items adjudication results
    fhir:adjudication  ( [ See ClaimResponse.item.adjudication ] ... ) ; # 0..* Added items adjudication
    fhir:detail ( [ # 0..* Insurer added line details
      fhir:traceNumber  ( [ Identifier ] ... ) ; # 0..* Number for tracking
      fhir:revenue [ CodeableConcept ] ; # 0..1 Revenue or cost center code
      fhir:productOrService [ CodeableConcept ] ; # 0..1 Billing, service, product, or drug code
      fhir:productOrServiceEnd [ CodeableConcept ] ; # 0..1 End of a range of codes
      fhir:modifier  ( [ CodeableConcept ] ... ) ; # 0..* Service/Product billing modifiers
      fhir:quantity [ Quantity(SimpleQuantity) ] ; # 0..1 Count of products or services
      fhir:unitPrice [ Money ] ; # 0..1 Fee, charge or cost per item
      fhir:factor [ decimal ] ; # 0..1 Price scaling factor
      fhir:tax [ Money ] ; # 0..1 Total tax
      fhir:net [ Money ] ; # 0..1 Total item cost
      fhir:noteNumber  ( [ positiveInt ] ... ) ; # 0..* Applicable note numbers
      fhir:reviewOutcome [ See ClaimResponse.item.reviewOutcome ] ; # 0..1 Added items detail level adjudication results
      fhir:adjudication  ( [ See ClaimResponse.item.adjudication ] ... ) ; # 0..* Added items detail adjudication
      fhir:subDetail ( [ # 0..* Insurer added line items
        fhir:traceNumber  ( [ Identifier ] ... ) ; # 0..* Number for tracking
        fhir:revenue [ CodeableConcept ] ; # 0..1 Revenue or cost center code
        fhir:productOrService [ CodeableConcept ] ; # 0..1 Billing, service, product, or drug code
        fhir:productOrServiceEnd [ CodeableConcept ] ; # 0..1 End of a range of codes
        fhir:modifier  ( [ CodeableConcept ] ... ) ; # 0..* Service/Product billing modifiers
        fhir:quantity [ Quantity(SimpleQuantity) ] ; # 0..1 Count of products or services
        fhir:unitPrice [ Money ] ; # 0..1 Fee, charge or cost per item
        fhir:factor [ decimal ] ; # 0..1 Price scaling factor
        fhir:tax [ Money ] ; # 0..1 Total tax
        fhir:net [ Money ] ; # 0..1 Total item cost
        fhir:noteNumber  ( [ positiveInt ] ... ) ; # 0..* Applicable note numbers
        fhir:reviewOutcome [ See ClaimResponse.item.reviewOutcome ] ; # 0..1 Added items subdetail level adjudication results
        fhir:adjudication  ( [ See ClaimResponse.item.adjudication ] ... ) ; # 0..* Added items subdetail adjudication
      ] ... ) ;
    ] ... ) ;
  ] ... ) ;
  fhir:adjudication  ( [ See ClaimResponse.item.adjudication ] ... ) ; # 0..* Header-level adjudication
  fhir:total ( [ # 0..* Adjudication totals
    fhir:category [ CodeableConcept ] ; # 1..1 Type of adjudication information
    fhir:amount [ Money ] ; # 1..1 Financial total for the category
  ] ... ) ;
  fhir:payment [ # 0..1 Payment Details
    fhir:type [ CodeableConcept ] ; # 1..1 Partial or complete payment
    fhir:adjustment [ Money ] ; # 0..1 Payment adjustment for non-claim issues
    fhir:adjustmentReason [ CodeableConcept ] ; # 0..1 Explanation for the adjustment
    fhir:date [ date ] ; # 0..1 Expected date of payment
    fhir:amount [ Money ] ; # 1..1 Payable amount after adjustment
    fhir:identifier [ Identifier ] ; # 0..1 Business identifier for the payment
  ] ;
  fhir:fundsReserve [ CodeableConcept ] ; # 0..1 Funds reserved status
  fhir:formCode [ CodeableConcept ] ; # 0..1 Printed form identifier
  fhir:form [ Attachment ] ; # 0..1 Printed reference or actual form
  fhir:processNote ( [ # 0..* Note concerning adjudication
    fhir:number [ positiveInt ] ; # 0..1 Note instance identifier
    fhir:type [ CodeableConcept ] ; # 0..1 Note purpose
    fhir:text [ string ] ; # 1..1 Note explanatory text
    fhir:language [ CodeableConcept ] ; # 0..1 Language of the text
  ] ... ) ;
  fhir:communicationRequest  ( [ Reference(CommunicationRequest) ] ... ) ; # 0..* Request for additional information
  fhir:insurance ( [ # 0..* Patient insurance information
    fhir:sequence [ positiveInt ] ; # 1..1 Insurance instance identifier
    fhir:focal [ boolean ] ; # 1..1 Coverage to be used for adjudication
    fhir:coverage [ Reference(Coverage) ] ; # 1..1 Insurance information
    fhir:businessArrangement [ string ] ; # 0..1 Additional provider contract number
    fhir:claimResponse [ Reference(ClaimResponse) ] ; # 0..1 Adjudication results
  ] ... ) ;
  fhir:error ( [ # 0..* Processing errors
    fhir:itemSequence [ positiveInt ] ; # 0..1 Item sequence number
    fhir:detailSequence [ positiveInt ] ; # 0..1 Detail sequence number
    fhir:subDetailSequence [ positiveInt ] ; # 0..1 Subdetail sequence number
    fhir:code [ CodeableConcept ] ; # 1..1 Error code detailing processing issues
    fhir:expression  ( [ string ] ... ) ; # 0..* FHIRPath of element(s) related to issue
  ] ... ) ;
]

Changes from both R4 and R4B

ClaimResponse
ClaimResponse.traceNumber
  • Added Element
ClaimResponse.insurer
  • Min Cardinality changed from 1 to 0
ClaimResponse.outcome
ClaimResponse.decision
  • Added Element
ClaimResponse.event
  • Added Element
ClaimResponse.event.type
  • Added Mandatory Element
ClaimResponse.event.when[x]
  • Added Mandatory Element
ClaimResponse.encounter
  • Added Element
ClaimResponse.diagnosisRelatedGroup
  • Added Element
ClaimResponse.item.traceNumber
  • Added Element
ClaimResponse.item.reviewOutcome
  • Added Element
ClaimResponse.item.reviewOutcome.decision
  • Added Element
ClaimResponse.item.reviewOutcome.reason
  • Added Element
ClaimResponse.item.reviewOutcome.preAuthRef
  • Added Element
ClaimResponse.item.reviewOutcome.preAuthPeriod
  • Added Element
ClaimResponse.item.adjudication
  • Min Cardinality changed from 1 to 0
ClaimResponse.item.adjudication.quantity
  • Added Element
ClaimResponse.item.detail.traceNumber
  • Added Element
ClaimResponse.item.detail.reviewOutcome
  • Added Element
ClaimResponse.item.detail.adjudication
  • Min Cardinality changed from 1 to 0
ClaimResponse.item.detail.subDetail.traceNumber
  • Added Element
ClaimResponse.item.detail.subDetail.reviewOutcome
  • Added Element
ClaimResponse.addItem.traceNumber
  • Added Element
ClaimResponse.addItem.revenue
  • Added Element
ClaimResponse.addItem.productOrService
  • Min Cardinality changed from 1 to 0
ClaimResponse.addItem.productOrServiceEnd
  • Added Element
ClaimResponse.addItem.request
  • Added Element
ClaimResponse.addItem.tax
  • Added Element
ClaimResponse.addItem.bodySite
  • Max Cardinality changed from 1 to *
  • Type changed from CodeableConcept to BackboneElement
ClaimResponse.addItem.bodySite.site
  • Added Mandatory Element
ClaimResponse.addItem.bodySite.subSite
  • Added Element
ClaimResponse.addItem.reviewOutcome
  • Added Element
ClaimResponse.addItem.adjudication
  • Min Cardinality changed from 1 to 0
ClaimResponse.addItem.detail.traceNumber
  • Added Element
ClaimResponse.addItem.detail.revenue
  • Added Element
ClaimResponse.addItem.detail.productOrService
  • Min Cardinality changed from 1 to 0
ClaimResponse.addItem.detail.productOrServiceEnd
  • Added Element
ClaimResponse.addItem.detail.tax
  • Added Element
ClaimResponse.addItem.detail.reviewOutcome
  • Added Element
ClaimResponse.addItem.detail.adjudication
  • Min Cardinality changed from 1 to 0
ClaimResponse.addItem.detail.subDetail.traceNumber
  • Added Element
ClaimResponse.addItem.detail.subDetail.revenue
  • Added Element
ClaimResponse.addItem.detail.subDetail.productOrService
  • Min Cardinality changed from 1 to 0
ClaimResponse.addItem.detail.subDetail.productOrServiceEnd
  • Added Element
ClaimResponse.addItem.detail.subDetail.tax
  • Added Element
ClaimResponse.addItem.detail.subDetail.reviewOutcome
  • Added Element
ClaimResponse.addItem.detail.subDetail.adjudication
  • Min Cardinality changed from 1 to 0
ClaimResponse.processNote.type
  • Type changed from code to CodeableConcept
  • Change binding strength from required to extensible
ClaimResponse.processNote.language
ClaimResponse.error.expression
  • Added Element
ClaimResponse.item.adjudication.value
  • Deleted
ClaimResponse.addItem.subSite
  • Deleted

See the Full Difference for further information

This analysis is available for R4 as XML or JSON and for R4B as XML or JSON.

See R4 <--> R5 Conversion Maps (status = See Conversions Summary.)

Structure

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 icon

See the Extensions for this resource

UML Diagram (Legend)

ClaimResponse (DomainResource)A unique identifier assigned to this claim responseidentifier : Identifier [0..*]Trace number for tracking purposes. May be defined at the jurisdiction level or between trading partnerstraceNumber : Identifier [0..*]The status of the resource instance (this element modifies the meaning of other elements)status : code [1..1] « null (Strength=Required)FinancialResourceStatusCodes! »A finer grained suite of claim type codes which may convey additional information such as Inpatient vs Outpatient and/or a specialty servicetype : CodeableConcept [1..1] « null (Strength=Extensible)ClaimTypeCodes+ »A finer grained suite of claim type codes which may convey additional information such as Inpatient vs Outpatient and/or a specialty servicesubType : CodeableConcept [0..1] « null (Strength=Example)ExampleClaimSubTypeCodes?? »A code to indicate whether the nature of the request is: Claim - A request to an Insurer to adjudicate the supplied charges for health care goods and services under the identified policy and to pay the determined Benefit amount, if any; Preauthorization - A request to an Insurer to adjudicate the supplied proposed future charges for health care goods and services under the identified policy and to approve the services and provide the expected benefit amounts and potentially to reserve funds to pay the benefits when Claims for the indicated services are later submitted; or, Pre-determination - A request to an Insurer to adjudicate the supplied 'what if' charges for health care goods and services under the identified policy and report back what the Benefit payable would be had the services actually been provideduse : code [1..1] « null (Strength=Required)Use! »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 soughtpatient : Reference [1..1] « Patient »The date this resource was createdcreated : dateTime [1..1]The party responsible for authorization, adjudication and reimbursementinsurer : Reference [0..1] « Organization »The provider which is responsible for the claim, predetermination or preauthorizationrequestor : Reference [0..1] « Practitioner|PractitionerRole| Organization »Original request resource referencerequest : Reference [0..1] « Claim »The outcome of the claim, predetermination, or preauthorization processingoutcome : code [1..1] « null (Strength=Required)ClaimProcessingCodes! »The result of the claim, predetermination, or preauthorization adjudicationdecision : CodeableConcept [0..1] « null (Strength=Example)ClaimAdjudicationDecisionsCod...?? »A human readable description of the status of the adjudicationdisposition : string [0..1]Reference from the Insurer which is used in later communications which refers to this adjudicationpreAuthRef : string [0..1]The time frame during which this authorization is effectivepreAuthPeriod : Period [0..1]Type of Party to be reimbursed: subscriber, provider, otherpayeeType : CodeableConcept [0..1] « null (Strength=Example)ClaimPayeeTypeCodes?? »Healthcare encounters related to this claimencounter : Reference [0..*] « Encounter »A package billing code or bundle code used to group products and services to a particular health condition (such as heart attack) which is based on a predetermined grouping code systemdiagnosisRelatedGroup : CodeableConcept [0..1] « null (Strength=Example) ExampleDiagnosisRelatedGroupC...?? »A code, used only on a response to a preauthorization, to indicate whether the benefits payable have been reserved and for whomfundsReserve : CodeableConcept [0..1] « null (Strength=Example)FundsReservationCodes?? »A code for the form to be used for printing the contentformCode : CodeableConcept [0..1] « null (Strength=Example)FormCodes?? »The actual form, by reference or inclusion, for printing the content or an EOBform : Attachment [0..1]Request for additional supporting or authorizing informationcommunicationRequest : Reference [0..*] « CommunicationRequest »EventA coded event such as when a service is expected or a card printedtype : CodeableConcept [1..1] « null (Strength=Example)DatesTypeCodes?? »A date or period in the past or future indicating when the event occurred or is expectd to occurwhen[x] : DataType [1..1] « dateTime|Period »ItemA number to uniquely reference the claim item entriesitemSequence : positiveInt [1..1]Trace number for tracking purposes. May be defined at the jurisdiction level or between trading partnerstraceNumber : Identifier [0..*]The numbers associated with notes below which apply to the adjudication of this itemnoteNumber : positiveInt [0..*]ReviewOutcomeThe result of the claim, predetermination, or preauthorization adjudicationdecision : CodeableConcept [0..1] « null (Strength=Example)ClaimAdjudicationDecisionsCod...?? »The reasons for the result of the claim, predetermination, or preauthorization adjudicationreason : CodeableConcept [0..*] « null (Strength=Example)ClaimAdjudicationDecisionReas...?? »Reference from the Insurer which is used in later communications which refers to this adjudicationpreAuthRef : string [0..1]The time frame during which this authorization is effectivepreAuthPeriod : Period [0..1]AdjudicationA 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 itemcategory : CodeableConcept [1..1] « null (Strength=Example)AdjudicationValueCodes?? »A code supporting the understanding of the adjudication result and explaining variance from expected amountreason : CodeableConcept [0..1] « null (Strength=Example)AdjudicationReasonCodes?? »Monetary amount associated with the categoryamount : Money [0..1]A non-monetary value associated with the category. Mutually exclusive to the amount element abovequantity : Quantity [0..1]ItemDetailA number to uniquely reference the claim detail entrydetailSequence : positiveInt [1..1]Trace number for tracking purposes. May be defined at the jurisdiction level or between trading partnerstraceNumber : Identifier [0..*]The numbers associated with notes below which apply to the adjudication of this itemnoteNumber : positiveInt [0..*]SubDetailA number to uniquely reference the claim sub-detail entrysubDetailSequence : positiveInt [1..1]Trace number for tracking purposes. May be defined at the jurisdiction level or between trading partnerstraceNumber : Identifier [0..*]The numbers associated with notes below which apply to the adjudication of this itemnoteNumber : positiveInt [0..*]AddedItemClaim items which this service line is intended to replaceitemSequence : positiveInt [0..*]The sequence number of the details within the claim item which this line is intended to replacedetailSequence : positiveInt [0..*]The sequence number of the sub-details within the details within the claim item which this line is intended to replacesubdetailSequence : positiveInt [0..*]Trace number for tracking purposes. May be defined at the jurisdiction level or between trading partnerstraceNumber : Identifier [0..*]The providers who are authorized for the services rendered to the patientprovider : Reference [0..*] « Practitioner|PractitionerRole| Organization »The type of revenue or cost center providing the product and/or servicerevenue : CodeableConcept [0..1] « null (Strength=Example)ExampleRevenueCenterCodes?? »When the value is a group code then this item collects a set of related item details, otherwise this contains the product, service, drug or other billing code for the item. This element may be the start of a range of .productOrService codes used in conjunction with .productOrServiceEnd or it may be a solo element where .productOrServiceEnd is not usedproductOrService : CodeableConcept [0..1] « null (Strength=Example)USCLSCodes?? »This contains the end of a range of product, service, drug or other billing codes for the item. This element is not used when the .productOrService is a group code. This value may only be present when a .productOfService code has been provided to convey the start of the range. Typically this value may be used only with preauthorizations and not with claimsproductOrServiceEnd : CodeableConcept [0..1] « null (Strength=Example)USCLSCodes?? »Request or Referral for Goods or Service to be renderedrequest : Reference [0..*] « DeviceRequest|MedicationRequest| NutritionOrder|ServiceRequest|SupplyRequest|VisionPrescription »Item typification or modifiers codes to convey additional context for the product or servicemodifier : CodeableConcept [0..*] « null (Strength=Example)ModifierTypeCodes?? »Identifies the program under which this may be recoveredprogramCode : CodeableConcept [0..*] « null (Strength=Example)ExampleProgramReasonCodes?? »The date or dates when the service or product was supplied, performed or completedserviced[x] : DataType [0..1] « date|Period »Where the product or service was providedlocation[x] : DataType [0..1] « CodeableConcept|Address|Reference( Location); null (Strength=Example)ExampleServicePlaceCodes?? »The number of repetitions of a service or productquantity : Quantity(SimpleQuantity) [0..1]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 groupunitPrice : Money [0..1]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 amountfactor : decimal [0..1]The total of taxes applicable for this product or servicetax : Money [0..1]The total amount claimed for the group (if a grouper) or the addItem. Net = unit price * quantity * factornet : Money [0..1]The numbers associated with notes below which apply to the adjudication of this itemnoteNumber : positiveInt [0..*]BodySitePhysical service site on the patient (limb, tooth, etc.)site : CodeableReference [1..*] « BodyStructure; null (Strength=Example)OralSiteCodes?? »A region or surface of the bodySite, e.g. limb region or tooth surface(s)subSite : CodeableConcept [0..*] « null (Strength=Example)SurfaceCodes?? »AddedItemDetailTrace number for tracking purposes. May be defined at the jurisdiction level or between trading partnerstraceNumber : Identifier [0..*]The type of revenue or cost center providing the product and/or servicerevenue : CodeableConcept [0..1] « null (Strength=Example)ExampleRevenueCenterCodes?? »When the value is a group code then this item collects a set of related item details, otherwise this contains the product, service, drug or other billing code for the item. This element may be the start of a range of .productOrService codes used in conjunction with .productOrServiceEnd or it may be a solo element where .productOrServiceEnd is not usedproductOrService : CodeableConcept [0..1] « null (Strength=Example)USCLSCodes?? »This contains the end of a range of product, service, drug or other billing codes for the item. This element is not used when the .productOrService is a group code. This value may only be present when a .productOfService code has been provided to convey the start of the range. Typically this value may be used only with preauthorizations and not with claimsproductOrServiceEnd : CodeableConcept [0..1] « null (Strength=Example)USCLSCodes?? »Item typification or modifiers codes to convey additional context for the product or servicemodifier : CodeableConcept [0..*] « null (Strength=Example)ModifierTypeCodes?? »The number of repetitions of a service or productquantity : Quantity(SimpleQuantity) [0..1]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 groupunitPrice : Money [0..1]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 amountfactor : decimal [0..1]The total of taxes applicable for this product or servicetax : Money [0..1]The total amount claimed for the group (if a grouper) or the addItem.detail. Net = unit price * quantity * factornet : Money [0..1]The numbers associated with notes below which apply to the adjudication of this itemnoteNumber : positiveInt [0..*]AddedItemSubDetailTrace number for tracking purposes. May be defined at the jurisdiction level or between trading partnerstraceNumber : Identifier [0..*]The type of revenue or cost center providing the product and/or servicerevenue : CodeableConcept [0..1] « null (Strength=Example)ExampleRevenueCenterCodes?? »When the value is a group code then this item collects a set of related item details, otherwise this contains the product, service, drug or other billing code for the item. This element may be the start of a range of .productOrService codes used in conjunction with .productOrServiceEnd or it may be a solo element where .productOrServiceEnd is not usedproductOrService : CodeableConcept [0..1] « null (Strength=Example)USCLSCodes?? »This contains the end of a range of product, service, drug or other billing codes for the item. This element is not used when the .productOrService is a group code. This value may only be present when a .productOfService code has been provided to convey the start of the range. Typically this value may be used only with preauthorizations and not with claimsproductOrServiceEnd : CodeableConcept [0..1] « null (Strength=Example)USCLSCodes?? »Item typification or modifiers codes to convey additional context for the product or servicemodifier : CodeableConcept [0..*] « null (Strength=Example)ModifierTypeCodes?? »The number of repetitions of a service or productquantity : Quantity(SimpleQuantity) [0..1]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 groupunitPrice : Money [0..1]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 amountfactor : decimal [0..1]The total of taxes applicable for this product or servicetax : Money [0..1]The total amount claimed for the addItem.detail.subDetail. Net = unit price * quantity * factornet : Money [0..1]The numbers associated with notes below which apply to the adjudication of this itemnoteNumber : positiveInt [0..*]TotalA 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 itemcategory : CodeableConcept [1..1] « null (Strength=Example)AdjudicationValueCodes?? »Monetary total amount associated with the categoryamount : Money [1..1]PaymentWhether this represents partial or complete payment of the benefits payabletype : CodeableConcept [1..1] « null (Strength=Example)ExamplePaymentTypeCodes?? »Total amount of all adjustments to this payment included in this transaction which are not related to this claim's adjudicationadjustment : Money [0..1]Reason for the payment adjustmentadjustmentReason : CodeableConcept [0..1] « null (Strength=Example) PaymentAdjustmentReasonCodes?? »Estimated date the payment will be issued or the actual issue date of paymentdate : date [0..1]Benefits payable less any payment adjustmentamount : Money [1..1]Issuer's unique identifier for the payment instrumentidentifier : Identifier [0..1]NoteA number to uniquely identify a note entrynumber : positiveInt [0..1]The business purpose of the note texttype : CodeableConcept [0..1] « null (Strength=Extensible)NoteType+ »The explanation or description associated with the processingtext : string [1..1]A code to define the language used in the text of the notelanguage : CodeableConcept [0..1] « null (Strength=Required)AllLanguages! »InsuranceA number to uniquely identify insurance entries and provide a sequence of coverages to convey coordination of benefit ordersequence : positiveInt [1..1]A flag to indicate that this Coverage is to be used for adjudication of this claim when set to truefocal : boolean [1..1]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 systemcoverage : Reference [1..1] « Coverage »A business agreement number established between the provider and the insurer for special business processing purposesbusinessArrangement : string [0..1]The result of the adjudication of the line items for the Coverage specified in this insuranceclaimResponse : Reference [0..1] « ClaimResponse »ErrorThe sequence number of the line item submitted which contains the error. This value is omitted when the error occurs outside of the item structureitemSequence : positiveInt [0..1]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 structuredetailSequence : positiveInt [0..1]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 structuresubDetailSequence : positiveInt [0..1]An error code, from a specified code system, which details why the claim could not be adjudicatedcode : CodeableConcept [1..1] « null (Strength=Example)AdjudicationErrorCodes?? »A [simple subset of FHIRPath](fhirpath.html#simple) limited to element names, repetition indicators and the default child accessor that identifies one of the elements in the resource that caused this issue to be raisedexpression : string [0..*]Information code for an event with a corresponding date or periodevent[0..*]The high-level results of the adjudication if adjudication has been performedreviewOutcome[0..1]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 itemadjudication[0..*]The high-level results of the adjudication if adjudication has been performedreviewOutcome[0..1]The adjudication resultsadjudication[0..*]The high-level results of the adjudication if adjudication has been performedreviewOutcome[0..1]The adjudication resultsadjudication[0..*]A sub-detail adjudication of a simple product or servicesubDetail[0..*]A claim detail. Either a simple (a product or service) or a 'group' of sub-details which are simple itemsdetail[0..*]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-detailsitem[0..*]Physical location where the service is performed or appliesbodySite[0..*]The high-level results of the adjudication if adjudication has been performedreviewOutcome[0..1]The adjudication resultsadjudication[0..*]The high-level results of the adjudication if adjudication has been performedreviewOutcome[0..1]The adjudication resultsadjudication[0..*]The high-level results of the adjudication if adjudication has been performedreviewOutcome[0..1]The adjudication resultsadjudication[0..*]The third-tier service adjudications for payor added servicessubDetail[0..*]The second-tier service adjudications for payor added servicesdetail[0..*]The first-tier service adjudications for payor added product or service linesaddItem[0..*]The adjudication results which are presented at the header level rather than at the line-item or add-item levelsadjudication[0..*]Categorized monetary totals for the adjudicationtotal[0..*]Payment details for the adjudication of the claimpayment[0..1]A note that describes or explains adjudication results in a human readable formprocessNote[0..*]Financial instruments for reimbursement for the health care products and services specified on the claiminsurance[0..*]Errors encountered during the processing of the adjudicationerror[0..*]

XML Template

<ClaimResponse xmlns="http://hl7.org/fhir"> doco
 <!-- from Resource: id, meta, implicitRules, and language -->
 <!-- from DomainResource: text, contained, extension, and modifierExtension -->
 <identifier><!-- 0..* Identifier Business Identifier for a claim response --></identifier>
 <traceNumber><!-- 0..* Identifier Number for tracking --></traceNumber>
 <status value="[code]"/><!-- 1..1 active | cancelled | draft | entered-in-error -->
 <type><!-- 1..1 CodeableConcept More granular claim type --></type>
 <subType><!-- 0..1 CodeableConcept More granular claim type --></subType>
 <use value="[code]"/><!-- 1..1 claim | preauthorization | predetermination -->
 <patient><!-- 1..1 Reference(Patient) The recipient of the products and services --></patient>
 <created value="[dateTime]"/><!-- 1..1 Response creation date -->
 <insurer><!-- 0..1 Reference(Organization) Party responsible for reimbursement --></insurer>
 <requestor><!-- 0..1 Reference(Organization|Practitioner|PractitionerRole) Party responsible for the claim --></requestor>
 <request><!-- 0..1 Reference(Claim) Id of resource triggering adjudication --></request>
 <outcome value="[code]"/><!-- 1..1 queued | complete | error | partial -->
 <decision><!-- 0..1 CodeableConcept Result of the adjudication --></decision>
 <disposition value="[string]"/><!-- 0..1 Disposition Message -->
 <preAuthRef value="[string]"/><!-- 0..1 Preauthorization reference -->
 <preAuthPeriod><!-- 0..1 Period Preauthorization reference effective period --></preAuthPeriod>
 <event>  <!-- 0..* Event information -->
  <type><!-- 1..1 CodeableConcept Specific event --></type>
  <when[x]><!-- 1..1 dateTime|Period Occurance date or period --></when[x]>
 </event>
 <payeeType><!-- 0..1 CodeableConcept Party to be paid any benefits payable --></payeeType>
 <encounter><!-- 0..* Reference(Encounter) Encounters associated with the listed treatments --></encounter>
 <diagnosisRelatedGroup><!-- 0..1 CodeableConcept Package billing code --></diagnosisRelatedGroup>
 <item>  <!-- 0..* Adjudication for claim line items -->
  <itemSequence value="[positiveInt]"/><!-- 1..1 Claim item instance identifier -->
  <traceNumber><!-- 0..* Identifier Number for tracking --></traceNumber>
  <noteNumber value="[positiveInt]"/><!-- 0..* Applicable note numbers -->
  <reviewOutcome>  <!-- 0..1 Adjudication results -->
   <decision><!-- 0..1 CodeableConcept Result of the adjudication --></decision>
   <reason><!-- 0..* CodeableConcept Reason for result of the adjudication --></reason>
   <preAuthRef value="[string]"/><!-- 0..1 Preauthorization reference -->
   <preAuthPeriod><!-- 0..1 Period Preauthorization reference effective period --></preAuthPeriod>
  </reviewOutcome>
  <adjudication>  <!-- 0..* Adjudication details -->
   <category><!-- 1..1 CodeableConcept Type of adjudication information --></category>
   <reason><!-- 0..1 CodeableConcept Explanation of adjudication outcome --></reason>
   <amount><!-- 0..1 Money Monetary amount --></amount>
   <quantity><!-- 0..1 Quantity Non-monetary value --></quantity>
  </adjudication>
  <detail>  <!-- 0..* Adjudication for claim details -->
   <detailSequence value="[positiveInt]"/><!-- 1..1 Claim detail instance identifier -->
   <traceNumber><!-- 0..* Identifier Number for tracking --></traceNumber>
   <noteNumber value="[positiveInt]"/><!-- 0..* Applicable note numbers -->
   <reviewOutcome><!-- 0..1 Content as for ClaimResponse.item.reviewOutcome Detail level adjudication results --></reviewOutcome>
   <adjudication><!-- 0..* Content as for ClaimResponse.item.adjudication Detail level adjudication details --></adjudication>
   <subDetail>  <!-- 0..* Adjudication for claim sub-details -->
    <subDetailSequence value="[positiveInt]"/><!-- 1..1 Claim sub-detail instance identifier -->
    <traceNumber><!-- 0..* Identifier Number for tracking --></traceNumber>
    <noteNumber value="[positiveInt]"/><!-- 0..* Applicable note numbers -->
    <reviewOutcome><!-- 0..1 Content as for ClaimResponse.item.reviewOutcome Subdetail level adjudication results --></reviewOutcome>
    <adjudication><!-- 0..* Content as for ClaimResponse.item.adjudication Subdetail level adjudication details --></adjudication>
   </subDetail>
  </detail>
 </item>
 <addItem>  <!-- 0..* Insurer added line items -->
  <itemSequence value="[positiveInt]"/><!-- 0..* Item sequence number -->
  <detailSequence value="[positiveInt]"/><!-- 0..* Detail sequence number -->
  <subdetailSequence value="[positiveInt]"/><!-- 0..* Subdetail sequence number -->
  <traceNumber><!-- 0..* Identifier Number for tracking --></traceNumber>
  <provider><!-- 0..* Reference(Organization|Practitioner|PractitionerRole) Authorized providers --></provider>
  <revenue><!-- 0..1 CodeableConcept Revenue or cost center code --></revenue>
  <productOrService><!-- 0..1 CodeableConcept Billing, service, product, or drug code --></productOrService>
  <productOrServiceEnd><!-- 0..1 CodeableConcept End of a range of codes --></productOrServiceEnd>
  <request><!-- 0..* Reference(DeviceRequest|MedicationRequest|NutritionOrder|
    ServiceRequest|SupplyRequest|VisionPrescription) Request or Referral for Service --></request>
  <modifier><!-- 0..* CodeableConcept Service/Product billing modifiers --></modifier>
  <programCode><!-- 0..* CodeableConcept Program the product or service is provided under --></programCode>
  <serviced[x]><!-- 0..1 date|Period Date or dates of service or product delivery --></serviced[x]>
  <location[x]><!-- 0..1 CodeableConcept|Address|Reference(Location) Place of service or where product was supplied --></location[x]>
  <quantity><!-- 0..1 Quantity(SimpleQuantity) Count of products or services --></quantity>
  <unitPrice><!-- 0..1 Money Fee, charge or cost per item --></unitPrice>
  <factor value="[decimal]"/><!-- 0..1 Price scaling factor -->
  <tax><!-- 0..1 Money Total tax --></tax>
  <net><!-- 0..1 Money Total item cost --></net>
  <bodySite>  <!-- 0..* Anatomical location -->
   <site><!-- 1..* CodeableReference(BodyStructure) Location --></site>
   <subSite><!-- 0..* CodeableConcept Sub-location --></subSite>
  </bodySite>
  <noteNumber value="[positiveInt]"/><!-- 0..* Applicable note numbers -->
  <reviewOutcome><!-- 0..1 Content as for ClaimResponse.item.reviewOutcome Added items adjudication results --></reviewOutcome>
  <adjudication><!-- 0..* Content as for ClaimResponse.item.adjudication Added items adjudication --></adjudication>
  <detail>  <!-- 0..* Insurer added line details -->
   <traceNumber><!-- 0..* Identifier Number for tracking --></traceNumber>
   <revenue><!-- 0..1 CodeableConcept Revenue or cost center code --></revenue>
   <productOrService><!-- 0..1 CodeableConcept Billing, service, product, or drug code --></productOrService>
   <productOrServiceEnd><!-- 0..1 CodeableConcept End of a range of codes --></productOrServiceEnd>
   <modifier><!-- 0..* CodeableConcept Service/Product billing modifiers --></modifier>
   <quantity><!-- 0..1 Quantity(SimpleQuantity) Count of products or services --></quantity>
   <unitPrice><!-- 0..1 Money Fee, charge or cost per item --></unitPrice>
   <factor value="[decimal]"/><!-- 0..1 Price scaling factor -->
   <tax><!-- 0..1 Money Total tax --></tax>
   <net><!-- 0..1 Money Total item cost --></net>
   <noteNumber value="[positiveInt]"/><!-- 0..* Applicable note numbers -->
   <reviewOutcome><!-- 0..1 Content as for ClaimResponse.item.reviewOutcome Added items detail level adjudication results --></reviewOutcome>
   <adjudication><!-- 0..* Content as for ClaimResponse.item.adjudication Added items detail adjudication --></adjudication>
   <subDetail>  <!-- 0..* Insurer added line items -->
    <traceNumber><!-- 0..* Identifier Number for tracking --></traceNumber>
    <revenue><!-- 0..1 CodeableConcept Revenue or cost center code --></revenue>
    <productOrService><!-- 0..1 CodeableConcept Billing, service, product, or drug code --></productOrService>
    <productOrServiceEnd><!-- 0..1 CodeableConcept End of a range of codes --></productOrServiceEnd>
    <modifier><!-- 0..* CodeableConcept Service/Product billing modifiers --></modifier>
    <quantity><!-- 0..1 Quantity(SimpleQuantity) Count of products or services --></quantity>
    <unitPrice><!-- 0..1 Money Fee, charge or cost per item --></unitPrice>
    <factor value="[decimal]"/><!-- 0..1 Price scaling factor -->
    <tax><!-- 0..1 Money Total tax --></tax>
    <net><!-- 0..1 Money Total item cost --></net>
    <noteNumber value="[positiveInt]"/><!-- 0..* Applicable note numbers -->
    <reviewOutcome><!-- 0..1 Content as for ClaimResponse.item.reviewOutcome Added items subdetail level adjudication results --></reviewOutcome>
    <adjudication><!-- 0..* Content as for ClaimResponse.item.adjudication Added items subdetail adjudication --></adjudication>
   </subDetail>
  </detail>
 </addItem>
 <adjudication><!-- 0..* Content as for ClaimResponse.item.adjudication Header-level adjudication --></adjudication>
 <total>  <!-- 0..* Adjudication totals -->
  <category><!-- 1..1 CodeableConcept Type of adjudication information --></category>
  <amount><!-- 1..1 Money Financial total for the category --></amount>
 </total>
 <payment>  <!-- 0..1 Payment Details -->
  <type><!-- 1..1 CodeableConcept Partial or complete payment --></type>
  <adjustment><!-- 0..1 Money Payment adjustment for non-claim issues --></adjustment>
  <adjustmentReason><!-- 0..1 CodeableConcept Explanation for the adjustment --></adjustmentReason>
  <date value="[date]"/><!-- 0..1 Expected date of payment -->
  <amount><!-- 1..1 Money Payable amount after adjustment --></amount>
  <identifier><!-- 0..1 Identifier Business identifier for the payment --></identifier>
 </payment>
 <fundsReserve><!-- 0..1 CodeableConcept Funds reserved status --></fundsReserve>
 <formCode><!-- 0..1 CodeableConcept Printed form identifier --></formCode>
 <form><!-- 0..1 Attachment Printed reference or actual form --></form>
 <processNote>  <!-- 0..* Note concerning adjudication -->
  <number value="[positiveInt]"/><!-- 0..1 Note instance identifier -->
  <type><!-- 0..1 CodeableConcept Note purpose --></type>
  <text value="[string]"/><!-- 1..1 Note explanatory text -->
  <language><!-- 0..1 CodeableConcept Language of the text --></language>
 </processNote>
 <communicationRequest><!-- 0..* Reference(CommunicationRequest) Request for additional information --></communicationRequest>
 <insurance>  <!-- 0..* Patient insurance information -->
  <sequence value="[positiveInt]"/><!-- 1..1 Insurance instance identifier -->
  <focal value="[boolean]"/><!-- 1..1 Coverage to be used for adjudication -->
  <coverage><!-- 1..1 Reference(Coverage) Insurance information --></coverage>
  <businessArrangement value="[string]"/><!-- 0..1 Additional provider contract number -->
  <claimResponse><!-- 0..1 Reference(ClaimResponse) Adjudication results --></claimResponse>
 </insurance>
 <error>  <!-- 0..* Processing errors -->
  <itemSequence value="[positiveInt]"/><!-- 0..1 Item sequence number -->
  <detailSequence value="[positiveInt]"/><!-- 0..1 Detail sequence number -->
  <subDetailSequence value="[positiveInt]"/><!-- 0..1 Subdetail sequence number -->
  <code><!-- 1..1 CodeableConcept Error code detailing processing issues --></code>
  <expression value="[string]"/><!-- 0..* FHIRPath of element(s) related to issue -->
 </error>
</ClaimResponse>

JSON Template

{doco
  "resourceType" : "ClaimResponse",
  // from Resource: id, meta, implicitRules, and language
  // from DomainResource: text, contained, extension, and modifierExtension
  "identifier" : [{ Identifier }], // Business Identifier for a claim response
  "traceNumber" : [{ Identifier }], // Number for tracking
  "status" : "<code>", // R!  active | cancelled | draft | entered-in-error
  "type" : { CodeableConcept }, // R!  More granular claim type
  "subType" : { CodeableConcept }, // More granular claim type
  "use" : "<code>", // R!  claim | preauthorization | predetermination
  "patient" : { Reference(Patient) }, // R!  The recipient of the products and services
  "created" : "<dateTime>", // R!  Response creation date
  "insurer" : { Reference(Organization) }, // Party responsible for reimbursement
  "requestor" : { Reference(Organization|Practitioner|PractitionerRole) }, // Party responsible for the claim
  "request" : { Reference(Claim) }, // Id of resource triggering adjudication
  "outcome" : "<code>", // R!  queued | complete | error | partial
  "decision" : { CodeableConcept }, // Result of the adjudication
  "disposition" : "<string>", // Disposition Message
  "preAuthRef" : "<string>", // Preauthorization reference
  "preAuthPeriod" : { Period }, // Preauthorization reference effective period
  "event" : [{ // Event information
    "type" : { CodeableConcept }, // R!  Specific event
    // when[x]: Occurance date or period. One of these 2:
    "whenDateTime" : "<dateTime>",
    "whenPeriod" : { Period }
  }],
  "payeeType" : { CodeableConcept }, // Party to be paid any benefits payable
  "encounter" : [{ Reference(Encounter) }], // Encounters associated with the listed treatments
  "diagnosisRelatedGroup" : { CodeableConcept }, // Package billing code
  "item" : [{ // Adjudication for claim line items
    "itemSequence" : "<positiveInt>", // R!  Claim item instance identifier
    "traceNumber" : [{ Identifier }], // Number for tracking
    "noteNumber" : ["<positiveInt>"], // Applicable note numbers
    "reviewOutcome" : { // Adjudication results
      "decision" : { CodeableConcept }, // Result of the adjudication
      "reason" : [{ CodeableConcept }], // Reason for result of the adjudication
      "preAuthRef" : "<string>", // Preauthorization reference
      "preAuthPeriod" : { Period } // Preauthorization reference effective period
    },
    "adjudication" : [{ // Adjudication detai