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

Detailed Descriptions for the elements in the ClaimResponse resource.

ClaimResponse
Element IdClaimResponse
Definition

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

Control1..1
Alternate NamesRemittance Advice
ClaimResponse.identifier
Element IdClaimResponse.identifier
Definition

The response business identifier.

NoteThis is a business identifer, not a resource identifier (see discussion)
Control0..*
TypeIdentifier
ClaimResponse.status
Element IdClaimResponse.status
Definition

The status of the resource instance.

Control0..1
Terminology BindingFinancial Resource Status Codes (Required)
Typecode
Is Modifiertrue (Reason: This element is labeled as a modifier because it is a status element that contains status entered-in-error which means that the resource should not be treated as valid)
Summarytrue
Comments

This element is labeled as a modifier because the status contains the code cancelled and entered-in-error that mark the response as not currently valid.

ClaimResponse.type
Element IdClaimResponse.type
Definition

The category of claim, e.g, oral, pharmacy, vision, institutional, professional.

Control0..1
Terminology BindingClaim Type Codes (Extensible)
TypeCodeableConcept
Comments

Affects which fields and value sets are used.

ClaimResponse.subType
Element IdClaimResponse.subType
Definition

A finer grained suite of claim subtype codes which may convey Inpatient vs Outpatient and/or a specialty service. In the US the CMS Bill Type.

Control0..*
Terminology BindingExample Claim SubType Codes (Example)
TypeCodeableConcept
Comments

This may contain the local bill type codes such as the US UB-04 bill type code.

ClaimResponse.use
Element IdClaimResponse.use
Definition

A claim, a list of completed goods and services; a preauthorization, a list or proposed goods and services; or a predetermination, a set of goods and services being considered, for which insurer adjudication is sought.

Control0..1
Terminology BindingUse (Required)
Typecode
Summarytrue
ClaimResponse.patient
Element IdClaimResponse.patient
Definition

Patient Resource.

Control0..1
TypeReference(Patient)
ClaimResponse.created
Element IdClaimResponse.created
Definition

The date when this resource was created.

Control0..1
TypedateTime
ClaimResponse.insurer
Element IdClaimResponse.insurer
Definition

The Insurer who produced this adjudicated response.

Control0..1
TypeReference(Organization)
ClaimResponse.requestProvider
Element IdClaimResponse.requestProvider
Definition

The practitioner who is responsible for the services rendered to the patient.

Control0..1
TypeReference(Practitioner | PractitionerRole | Organization)
ClaimResponse.request
Element IdClaimResponse.request
Definition

Original request resource reference.

Control0..1
TypeReference(Claim)
ClaimResponse.outcome
Element IdClaimResponse.outcome
Definition

Transaction: error, complete, partial processing.

Control0..1
Terminology BindingClaim Processing Codes (Required)
Typecode
ClaimResponse.disposition
Element IdClaimResponse.disposition
Definition

A description of the status of the adjudication.

Control0..1
Typestring
ClaimResponse.payeeType
Element IdClaimResponse.payeeType
Definition

Party to be reimbursed: Subscriber, provider, other.

Control0..1
Terminology BindingClaim Payee Type Codes (Example)
TypeCodeableConcept
ClaimResponse.item
Element IdClaimResponse.item
Definition

The first-tier service adjudications for submitted services.

Control0..*
ClaimResponse.item.itemSequence
Element IdClaimResponse.item.itemSequence
Definition

A service line number.

Control1..1
TypepositiveInt
ClaimResponse.item.noteNumber
Element IdClaimResponse.item.noteNumber
Definition

A list of note references to the notes provided below.

Control0..*
TypepositiveInt
ClaimResponse.item.adjudication
Element IdClaimResponse.item.adjudication
Definition

The adjudication results.

Control0..*
ClaimResponse.item.adjudication.category
Element IdClaimResponse.item.adjudication.category
Definition

Code indicating: Co-Pay, deductible, eligible, benefit, tax, etc.

Control1..1
Terminology BindingAdjudication Value Codes (Example)
TypeCodeableConcept
ClaimResponse.item.adjudication.reason
Element IdClaimResponse.item.adjudication.reason
Definition

Adjudication reason such as limit reached.

Control0..1
Terminology BindingAdjudication Reason Codes (Example)
TypeCodeableConcept
ClaimResponse.item.adjudication.amount
Element IdClaimResponse.item.adjudication.amount
Definition

Monetary amount associated with the code.

Control0..1
TypeMoney
ClaimResponse.item.adjudication.value
Element IdClaimResponse.item.adjudication.value
Definition

A non-monetary value for example a percentage. Mutually exclusive to the amount element above.

Control0..1
Typedecimal
ClaimResponse.item.detail
Element IdClaimResponse.item.detail
Definition

The second-tier service adjudications for submitted services.

Control0..*
ClaimResponse.item.detail.detailSequence
Element IdClaimResponse.item.detail.detailSequence
Definition

A service line number.

Control1..1
TypepositiveInt
ClaimResponse.item.detail.noteNumber
Element IdClaimResponse.item.detail.noteNumber
Definition

A list of note references to the notes provided below.

Control0..*
TypepositiveInt
ClaimResponse.item.detail.adjudication
Element IdClaimResponse.item.detail.adjudication
Definition

The adjudication results.

Control0..*
TypeSee ClaimResponse.item.adjudication
ClaimResponse.item.detail.subDetail
Element IdClaimResponse.item.detail.subDetail
Definition

The third-tier service adjudications for submitted services.

Control0..*
ClaimResponse.item.detail.subDetail.subDetailSequence
Element IdClaimResponse.item.detail.subDetail.subDetailSequence
Definition

A service line number.

Control1..1
TypepositiveInt
ClaimResponse.item.detail.subDetail.noteNumber
Element IdClaimResponse.item.detail.subDetail.noteNumber
Definition

A list of note references to the notes provided below.

Control0..*
TypepositiveInt
ClaimResponse.item.detail.subDetail.adjudication
Element IdClaimResponse.item.detail.subDetail.adjudication
Definition

The adjudication results.

Control0..*
TypeSee ClaimResponse.item.adjudication
ClaimResponse.addItem
Element IdClaimResponse.addItem
Definition

The first-tier service adjudications for payor added services.

Control0..*
ClaimResponse.addItem.itemSequence
Element IdClaimResponse.addItem.itemSequence
Definition

List of input service items which this service line is intended to replace.

Control0..*
TypepositiveInt
ClaimResponse.addItem.detailSequence
Element IdClaimResponse.addItem.detailSequence
Definition

The sequence number of the addition within the line item submitted which contains the error. This value is omitted when the error is not related to an Addition.

Control0..*
TypepositiveInt
ClaimResponse.addItem.subdetailSequence
Element IdClaimResponse.addItem.subdetailSequence
Definition

The sequence number of the addition within the line item submitted which contains the error. This value is omitted when the error is not related to an Addition.

Control0..*
TypepositiveInt
ClaimResponse.addItem.provider
Element IdClaimResponse.addItem.provider
Definition

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

Control0..*
TypeReference(Practitioner | PractitionerRole | Organization)
ClaimResponse.addItem.billcode
Element IdClaimResponse.addItem.billcode
Definition

A code to indicate the Professional Service or Product supplied.

Control0..1
Terminology BindingUSCLS Codes (Example)
TypeCodeableConcept
ClaimResponse.addItem.modifier
Element IdClaimResponse.addItem.modifier
Definition

Item typification or modifiers codes, e.g. for Oral whether the treatment is cosmetic or associated with TMJ, or for medical whether the treatment was outside the clinic or out of office hours.

Control0..*
Terminology BindingModifier type Codes (Example)
TypeCodeableConcept
Requirements

May impact on adjudication.

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

For programs which require reason codes for the inclusion or covering of this billed item under the program or sub-program.

Control0..*
Terminology BindingExample Program Reason Codes (Example)
TypeCodeableConcept
ClaimResponse.addItem.serviced[x]
Element IdClaimResponse.addItem.serviced[x]
Definition

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

Control0..1
Typedate|Period
[x] NoteSee Choice of Data Types for further information about how to use [x]
ClaimResponse.addItem.location[x]
Element IdClaimResponse.addItem.location[x]
Definition

Where the service was provided.

Control0..1
Terminology BindingExample Service Place Codes (Example)
TypeCodeableConcept|Address|Reference(Location)
[x] NoteSee Choice of Data Types for further information about how to use [x]
ClaimResponse.addItem.quantity
Element IdClaimResponse.addItem.quantity
Definition

The number of repetitions of a service or product.

Control0..1
TypeSimpleQuantity
ClaimResponse.addItem.unitPrice
Element IdClaimResponse.addItem.unitPrice
Definition

If the item is a node then this is the fee for the product or service, otherwise this is the total of the fees for the children of the group.

Control0..1
TypeMoney
ClaimResponse.addItem.factor
Element IdClaimResponse.addItem.factor
Definition

A real number that represents a multiplier used in determining the overall value of services delivered and/or goods received. The concept of a Factor allows for a discount or surcharge multiplier to be applied to a monetary amount.

Control0..1
Typedecimal
Requirements

If a fee is present the associated product/service code must be present.

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

The quantity times the unit price for an additional service or product or charge. For example, the formula: unit Quantity * unit Price (Cost per Point) * factor Number * points = net Amount. Quantity, factor and points are assumed to be 1 if not supplied.

Control0..1
TypeMoney
Requirements

If a fee is present the associated product/service code must be present.

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

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

Control0..1
Terminology BindingOral Site Codes (Example)
TypeCodeableConcept
ClaimResponse.addItem.subSite
Element IdClaimResponse.addItem.subSite
Definition

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

Control0..*
Terminology BindingSurface Codes (Example)
TypeCodeableConcept
ClaimResponse.addItem.noteNumber
Element IdClaimResponse.addItem.noteNumber
Definition

A list of note references to the notes provided below.

Control0..*
TypepositiveInt
ClaimResponse.addItem.adjudication
Element IdClaimResponse.addItem.adjudication
Definition

The adjudication results.

Control0..*
TypeSee ClaimResponse.item.adjudication
ClaimResponse.addItem.detail
Element IdClaimResponse.addItem.detail
Definition

The second-tier service adjudications for payor added services.

Control0..*
ClaimResponse.addItem.detail.billcode
Element IdClaimResponse.addItem.detail.billcode
Definition

A code to indicate the Professional Service or Product supplied.

Control0..1
Terminology BindingUSCLS Codes (Example)
TypeCodeableConcept
ClaimResponse.addItem.detail.modifier
Element IdClaimResponse.addItem.detail.modifier
Definition

Item typification or modifiers codes, e.g. for Oral whether the treatment is cosmetic or associated with TMJ, or for medical whether the treatment was outside the clinic or out of office hours.

Control0..*
Terminology BindingModifier type Codes (Example)
TypeCodeableConcept
Requirements

May impact on adjudication.

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

The number of repetitions of a service or product.

Control0..1
TypeSimpleQuantity
ClaimResponse.addItem.detail.unitPrice
Element IdClaimResponse.addItem.detail.unitPrice
Definition

If the item is a node then this is the fee for the product or service, otherwise this is the total of the fees for the children of the group.

Control0..1
TypeMoney
ClaimResponse.addItem.detail.factor
Element IdClaimResponse.addItem.detail.factor
Definition

A real number that represents a multiplier used in determining the overall value of services delivered and/or goods received. The concept of a Factor allows for a discount or surcharge multiplier to be applied to a monetary amount.

Control0..1
Typedecimal
Requirements

If a fee is present the associated product/service code must be present.

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

The quantity times the unit price for an additional service or product or charge. For example, the formula: unit Quantity * unit Price (Cost per Point) * factor Number * points = net Amount. Quantity, factor and points are assumed to be 1 if not supplied.

Control0..1
TypeMoney
Requirements

If a fee is present the associated product/service code must be present.

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

A list of note references to the notes provided below.

Control0..*
TypepositiveInt
ClaimResponse.addItem.detail.adjudication
Element IdClaimResponse.addItem.detail.adjudication
Definition

The adjudication results.

Control0..*
TypeSee ClaimResponse.item.adjudication
ClaimResponse.addItem.detail.subDetail
Element IdClaimResponse.addItem.detail.subDetail
Definition

The third-tier service adjudications for payor added services.

Control0..*
ClaimResponse.addItem.detail.subDetail.billcode
Element IdClaimResponse.addItem.detail.subDetail.billcode
Definition

A code to indicate the Professional Service or Product supplied.

Control0..1
Terminology BindingUSCLS Codes (Example)
TypeCodeableConcept
ClaimResponse.addItem.detail.subDetail.modifier
Element IdClaimResponse.addItem.detail.subDetail.modifier
Definition

Item typification or modifiers codes, e.g. for Oral whether the treatment is cosmetic or associated with TMJ, or for medical whether the treatment was outside the clinic or out of office hours.

Control0..*
Terminology BindingModifier type Codes (Example)
TypeCodeableConcept
Requirements

May impact on adjudication.

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

The number of repetitions of a service or product.

Control0..1
TypeSimpleQuantity
ClaimResponse.addItem.detail.subDetail.unitPrice
Element IdClaimResponse.addItem.detail.subDetail.unitPrice
Definition

If the item is a node then this is the fee for the product or service, otherwise this is the total of the fees for the children of the group.

Control0..1
TypeMoney
ClaimResponse.addItem.detail.subDetail.factor
Element IdClaimResponse.addItem.detail.subDetail.factor
Definition

A real number that represents a multiplier used in determining the overall value of services delivered and/or goods received. The concept of a Factor allows for a discount or surcharge multiplier to be applied to a monetary amount.

Control0..1
Typedecimal
Requirements

If a fee is present the associated product/service code must be present.

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

The quantity times the unit price for an additional service or product or charge. For example, the formula: unit Quantity * unit Price (Cost per Point) * factor Number * points = net Amount. Quantity, factor and points are assumed to be 1 if not supplied.

Control0..1
TypeMoney
Requirements

If a fee is present the associated product/service code must be present.

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

A list of note references to the notes provided below.

Control0..*
TypepositiveInt
ClaimResponse.addItem.detail.subDetail.adjudication
Element IdClaimResponse.addItem.detail.subDetail.adjudication
Definition

The adjudication results.

Control0..*
TypeSee ClaimResponse.item.adjudication
ClaimResponse.error
Element IdClaimResponse.error
Definition

Mutually exclusive with Services Provided (Item).

Control0..*
ClaimResponse.error.itemSequence
Element IdClaimResponse.error.itemSequence
Definition

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

Control0..1
TypepositiveInt
ClaimResponse.error.detailSequence
Element IdClaimResponse.error.detailSequence
Definition

The sequence number of the addition within the line item submitted which contains the error. This value is omitted when the error is not related to an Addition.

Control0..1
TypepositiveInt
ClaimResponse.error.subDetailSequence
Element IdClaimResponse.error.subDetailSequence
Definition

The sequence number of the addition within the line item submitted which contains the error. This value is omitted when the error is not related to an Addition.

Control0..1
TypepositiveInt
ClaimResponse.error.code
Element IdClaimResponse.error.code
Definition

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

Control1..1
Terminology BindingAdjudication Error Codes (Example)
TypeCodeableConcept
ClaimResponse.total
Element IdClaimResponse.total
Definition

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

Control0..*
ClaimResponse.total.category
Element IdClaimResponse.total.category
Definition

Code indicating: Submitted, Co-Pay, deductible, eligible, benefit, tax, etc.

Control1..1
Terminology BindingAdjudication Value Codes (Example)
TypeCodeableConcept
ClaimResponse.total.amount
Element IdClaimResponse.total.amount
Definition

Monitory amount associated with the code.

Control1..1
TypeMoney
ClaimResponse.payment
Element IdClaimResponse.payment
Definition

Payment details for the claim if the claim has been paid.

Control0..1
ClaimResponse.payment.type
Element IdClaimResponse.payment.type
Definition

Whether this represents partial or complete payment of the claim.

Control0..1
Terminology BindingExample Payment Type Codes (Example)
TypeCodeableConcept
ClaimResponse.payment.adjustment
Element IdClaimResponse.payment.adjustment
Definition

Adjustment to the payment of this transaction which is not related to adjudication of this transaction.

Control0..1
TypeMoney
ClaimResponse.payment.adjustmentReason
Element IdClaimResponse.payment.adjustmentReason
Definition

Reason for the payment adjustment.

Control0..1
Terminology BindingPayment Adjustment Reason Codes (Example)
TypeCodeableConcept
ClaimResponse.payment.date
Element IdClaimResponse.payment.date
Definition

Estimated payment data.

Control0..1
Typedate
ClaimResponse.payment.amount
Element IdClaimResponse.payment.amount
Definition

Payable less any payment adjustment.

Control0..1
TypeMoney
ClaimResponse.payment.identifier
Element IdClaimResponse.payment.identifier
Definition

Payment identifier.

NoteThis is a business identifer, not a resource identifier (see discussion)
Control0..1
TypeIdentifier
ClaimResponse.reserved
Element IdClaimResponse.reserved
Definition

Status of funds reservation (For provider, for Patient, None).

Control0..1
Terminology BindingFunds Reservation Codes (Example)
TypeCoding
ClaimResponse.form
Element IdClaimResponse.form
Definition

The form to be used for printing the content.

Control0..1
Terminology BindingForm Codes (Example)
TypeCodeableConcept
ClaimResponse.processNote
Element IdClaimResponse.processNote
Definition

Note text.

Control0..*
ClaimResponse.processNote.number
Element IdClaimResponse.processNote.number
Definition

An integer associated with each note which may be referred to from each service line item.

Control0..1
TypepositiveInt
ClaimResponse.processNote.type
Element IdClaimResponse.processNote.type
Definition

The note purpose: Print/Display.

Control0..1
Terminology BindingNoteType (Required)
Typecode
ClaimResponse.processNote.text
Element IdClaimResponse.processNote.text
Definition

The note text.

Control0..1
Typestring
ClaimResponse.processNote.language
Element IdClaimResponse.processNote.language
Definition

The ISO-639-1 alpha 2 code in lower case for the language, optionally followed by a hyphen and the ISO-3166-1 alpha 2 code for the region in upper case; e.g. "en" for English, or "en-US" for American English versus "en-EN" for England English.

Control0..1
Terminology BindingCommon Languages (Extensible but limited to All Languages)
TypeCodeableConcept
ClaimResponse.communicationRequest
Element IdClaimResponse.communicationRequest
Definition

Request for additional supporting or authorizing information, such as: documents, images or resources.

Control0..*
TypeReference(CommunicationRequest)
ClaimResponse.insurance
Element IdClaimResponse.insurance
Definition

Financial instrument by which payment information for health care.

Control0..*
Requirements

Health care programs and insurers are significant payors of health service costs.

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

A service line item.

Control1..1
TypepositiveInt
Requirements

To maintain order of the coverages.

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

The instance number of the Coverage which is the focus for adjudication. The Coverage against which the claim is to be adjudicated.

Control1..1
Typeboolean
Requirements

To identify which coverage is being adjudicated.

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

Reference to the program or plan identification, underwriter or payor.

Control1..1
TypeReference(Coverage)
Requirements

Need to identify the issuer to target for processing and for coordination of benefit processing.

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

The contract number of a business agreement which describes the terms and conditions.

Control0..1
Typestring
ClaimResponse.insurance.preAuthRef
Element IdClaimResponse.insurance.preAuthRef
Definition

A list of references from the Insurer to which these services pertain.

Control0..*
Typestring
Requirements

To provide any pre-determination or prior authorization reference.

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

The Coverages adjudication details.

Control0..1
TypeReference(ClaimResponse)
Requirements

Used by downstream payers to determine what balance remains and the net payable.