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

A reference to a set of rules that were followed when the resource was constructed, and which must be understood when processing the content. Often, this is a reference to an implementation guide that defines the special rules along with other profiles etc.

Asserting this rule set restricts the content to be only understood by a limited set of trading partners. This inherently limits the usefulness of the data in the long term. However, the existing health eco-system is highly fractured, and not yet ready to define, collect, and exchange data in a generally computable sense. Wherever possible, implementers and/or specification writers should avoid using this element. Often, when used, the URL is a reference to an implementation guide that defines these special rules as part of it's narrative along with other profiles, value sets, etc.

An Extension

Identifiers used for transmission tracking. Used in the X12 GS and ISA header segments.

A string assigned by the UMO to the original disallowed review outcome associated with this service item.

A code representing the diagnosis that is the subject of the communication

The responsible practitioner who reviewed to the request.

The specific provider who has been authorized to provide this item.

A string assigned by the UMO to an authorized review outcome associated with this service item.

May be used to represent additional information that is not part of the basic definition of the resource and that modifies the understanding of the element that contains it and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

A unique identifier assigned to this claim response.

Allows claim responses to be distinguished and referenced.

An additional element that provides a further subdivision within the organization granting the identifier.

An additional element that provides the assigning jurisdiction of the identifier (i.e., provider state license number or state driver's license) so that it does not need to be mapped from the identifier system.

The purpose of this identifier.

Applications can assume that an identifier is permanent unless it explicitly says that it is temporary.

Identifies the purpose for this identifier, if known .

Allows the appropriate identifier for a particular context of use to be selected from among a set of identifiers.

Establishes the namespace for the value - that is, a URL that describes a set values that are unique.

Identifier.system is always case sensitive.

There are many sets of identifiers. To perform matching of two identifiers, we need to know what set we're dealing with. The system identifies a particular set of unique identifiers.

The portion of the identifier typically relevant to the user and which is unique within the context of the system.

If the value is a full URI, then the system SHALL be urn:ietf:rfc:3986. The value's primary purpose is computational mapping. As a result, it may be normalized for comparison purposes (e.g. removing non-significant whitespace, dashes, etc.) A value formatted for human display can be conveyed using the Rendered Value extension. Identifier.value is to be treated as case sensitive unless knowledge of the Identifier.system allows the processer to be confident that non-case-sensitive processing is safe.

The status of the resource instance.

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

A code specifying the state of the resource instance.

Need to track the status of the resource as 'draft' resources may undergo further edits while 'active' resources are immutable and may only have their status changed to 'cancelled'.

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

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

The type or discipline-style of the claim.

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

A code to indicate whether the nature of the request is: to request adjudication of products and services previously rendered; or requesting authorization and adjudication for provision in the future; or requesting the non-binding adjudication of the listed products and services which could be provided in the future.

Claim, preauthorization, predetermination.

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

The party to whom the professional services and/or products have been supplied or are being considered and for whom actual for facast reimbursement is sought.

The patient must be supplied to the insurer so that confirmation of coverage and service hstory may be considered as part of the authorization and/or adjudiction.

The date this resource was created.

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

The party responsible for authorization, adjudication and reimbursement.

To be a valid claim, preauthorization or predetermination there must be a party who is responsible for adjudicating the contents against a policy which provides benefits for the patient.

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

Typically this field would be 1..1 where this party is responsible for the claim but not necessarily professionally responsible for the provision of the individual products and services listed below.

Original request resource reference.

Provides a reason why the expected value or elements in the element that is extended are missing.

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

The resource may be used to indicate that: the request has been held (queued) for processing; that it has been processed and errors found (error); that no errors were found and that some of the adjudication has been undertaken (partial) or that all of the adjudication has been undertaken (complete).

To advise the requestor of an overall processing outcome.

An Extension

The BHT06 code pertaining to the ClaimResponse outcome.

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

This value is only present on preauthorization adjudications.

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

The time frame during which this authorization is effective.

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

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

The adjudication for items provided on the claim.

An Extension

Uniquely identifies this claim item. (2000F-TRN)

The date when this item's preauthorization was issued.

The date/period when this item's preauthorization is valid.

A string assigned by the UMO to an authorized review outcome associated with this service item.

A string assigned by the UMO to the original disallowed review outcome associated with this service item.

The original date/period that was requested by the submitter for this item.

The specific provider who has been authorized to provide this item.

The details of what has been authorized for this item.

The authorized admission dates for inpatient services.

The authorized discharge date for inpatient services.

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

A number to uniquely reference the claim item entries.

Each item returned on the PAS ClaimResponse SHALL echo the same item sequence number as that same item had on the Claim. The item.sequence element SHALL serve as the main tracing identifier of items throughout requests and responses.

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

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

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

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

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

An Extension

The details of the review action that is necessary for the authorization.

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

A code to indicate the information type of this adjudication record. Information types may include the value submitted, maximum values or percentages allowed or payable under the plan, amounts that: the patient is responsible for in aggregate or pertaining to this item; amounts paid by other coverages; and, the benefit payable for this item.

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

The adjudication codes.

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

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

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

An Extension

Uniquely identifies this claim item. (2000F-TRN)

The date when this item's preauthorization was issued.

The date/period when this item's preauthorization is valid.

A string assigned by the UMO to an authorized review outcome associated with this service item.

A string assigned by the UMO to the original disallowed review outcome associated with this service item.

An indicator of whether early and periodic screen for diagnosis and treatment of children is involved.

A code specifying the status of a nursing home resident at the time of service. (SV209)

A code specifying the level of care provided by a nursing home facility. (SV120, SV210)

Used to provide the last code in a series of codes for the service being requested.

A revenue code that expresses what was approved which maps to X12 SV201

The limit on the rate per unit of revenue for hospital accomodation. (SV206)

The details of the service being requested.

A code that identifies the type of service being requested.

A code representing the type of certification being requested (UM02)

The claim item category being responded to.

The authorized admission dates for inpatient services.

The authorized discharge date for inpatient services.

A code representing the diagnosis that is the subject of the communication

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

Claim items which this service line is intended to replace.

Provides references to the claim items.

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

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

The type of provider who has been authorized to provide this item.

When the value is a group code then this item collects a set of related claim details, otherwise this contains the product, service, drug or other billing code for the item.

If this is an actual service or product line, i.e. not a Group, then use code to indicate the Professional Service or Product supplied (e.g. CTP, HCPCS, USCLS, ICD10, NCPDP, DIN, RxNorm, ACHI, CCI). If a grouping item then use a group code to indicate the type of thing being grouped e.g. 'glasses' or 'compound'.

Necessary to state what was provided or done.

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

For example in Oral whether the treatment is cosmetic or associated with TMJ, or for Medical whether the treatment was outside the clinic or outside of office hours.

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

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

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

Where the product or service was provided.

Place of service: pharmacy, school, prison, etc.

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

The number of repetitions of a service or product.

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

If the item is not a group then this is the fee for the product or service, otherwise this is the total of the fees for the details of the group.

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

The adjudication results.

An Extension

The details of the review action that is necessary for the authorization.

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

A code to indicate the information type of this adjudication record. Information types may include the value submitted, maximum values or percentages allowed or payable under the plan, amounts that: the patient is responsible for in aggregate or pertaining to this item; amounts paid by other coverages; and, the benefit payable for this item.

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

The adjudication codes.

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

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

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

An Extension

The details of the review action that is necessary for the authorization.

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

A code to indicate the information type of this adjudication record. Information types may include the value submitted, maximum values or percentages allowed or payable under the plan, amounts that: the patient is responsible for in aggregate or pertaining to this item; amounts paid by other coverages; and, the benefit payable for this item.

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

The adjudication codes.

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

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

Provides the insurer specific textual explanations associated with the processing.

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

A number to uniquely identify a note entry.

Necessary to provide a mechanism to link from adjudications.

The explanation or description associated with the processing.

Required to provide human readable explanation.

Errors encountered during the processing of the adjudication.

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

Need to communicate processing issues to the requestor.

An Extension

A code representing what action must occur to resolve this error.

The specific loop, segment, or element that this error information is about. The string will follow the X12 format for specifying elements and is returned from the Payer. Example: 2010A-NM103

The FHIRPath expression that indicates which FHIR element that this error information is about. The expression will start with the Bundle and can be followed to determine the specific element.

STU NOTE: We would like feedback during the STU period on whether this extension is sufficient for implementers to determine and display the errored element.

Examples: Bundle.entry[1].resource.name, Bundle.entry[0].resource.identifier[0].value

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

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

Required to convey processing errors.

Each item returned on the PAS ClaimResponse SHALL echo the same item sequence number as that same item had on the Claim. The item.sequence element SHALL serve as the main tracing identifier of items throughout requests and responses.