description: This resource provides the adjudication details from the processing of a Claim resource.
package_name: hl7.fhir.core
derivation: specialization
name: ClaimResponse
type: ClaimResponse
elements:
  patient:
    short: The subject of the Products and Services
    refers: ['http://hl7.org/fhir/StructureDefinition/Patient']
    type: Reference
    index: 5
  payeeType:
    type: CodeableConcept
    short: Party to be paid any benefits payable
    binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/payeetype'}
    index: 13
  insurance:
    short: Insurance or medical plan
    type: BackboneElement
    array: true
    index: 96
    elements:
      sequence: {type: positiveInt, short: Service instance identifier, index: 97}
      focal: {type: boolean, short: Is the focal Coverage, index: 98}
      coverage:
        short: Insurance information
        refers: ['http://hl7.org/fhir/StructureDefinition/Coverage']
        type: Reference
        index: 99
      businessArrangement: {type: string, short: Business agreement, index: 100}
      claimResponse:
        short: Adjudication results
        refers: ['http://hl7.org/fhir/StructureDefinition/ClaimResponse']
        type: Reference
        index: 101
    required: [coverage, focal, sequence]
  request:
    short: Id of resource triggering adjudication
    refers: ['http://hl7.org/fhir/StructureDefinition/Claim']
    type: Reference
    index: 9
  requestProvider:
    short: Responsible practitioner
    refers: ['http://hl7.org/fhir/StructureDefinition/Organization', 'http://hl7.org/fhir/StructureDefinition/Practitioner', 'http://hl7.org/fhir/StructureDefinition/PractitionerRole']
    type: Reference
    index: 8
  processNote:
    type: BackboneElement
    short: Processing notes
    array: true
    index: 90
    elements:
      number: {type: positiveInt, short: Sequence Number for this note, index: 91}
      type:
        type: code
        short: display | print | printoper
        binding: {strength: required, valueSet: 'http://hl7.org/fhir/ValueSet/note-type'}
        index: 92
      text: {type: string, short: Note explanatory text, index: 93}
      language:
        type: CodeableConcept
        short: Language if different from the resource
        binding: {strength: preferred, valueSet: 'http://hl7.org/fhir/ValueSet/languages'}
        index: 94
  preAuthRef: {type: string, short: Pre-Authorization/Determination Reference, index: 12}
  use:
    short: claim | preauthorization | predetermination
    type: code
    binding: {strength: required, valueSet: 'http://hl7.org/fhir/ValueSet/claim-use'}
    isSummary: true
    index: 4
  payment:
    type: BackboneElement
    short: Payment Details
    index: 81
    elements:
      type:
        type: CodeableConcept
        short: Partial or Complete
        binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/ex-paymenttype'}
        index: 82
      adjustment: {type: Money, short: Payment adjustment for non-Claim issues, index: 83}
      adjustmentReason:
        type: CodeableConcept
        short: Explanation for the non-claim adjustment
        binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/payment-adjustment-reason'}
        index: 84
      date: {type: date, short: Expected data of Payment, index: 85}
      amount: {type: Money, short: Payable amount after adjustment, index: 86}
      identifier: {type: Identifier, short: Identifier of the payment instrument, index: 87}
  item:
    type: BackboneElement
    short: Line items
    array: true
    index: 14
    elements:
      itemSequence: {type: positiveInt, short: Service instance, index: 15}
      noteNumber: {type: positiveInt, short: List of note numbers which apply, array: true, index: 16}
      adjudication:
        type: BackboneElement
        short: Adjudication details
        array: true
        index: 17
        elements:
          category:
            type: CodeableConcept
            short: Adjudication category such as co-pay, eligible, benefit, etc.
            binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/adjudication'}
            index: 18
          reason:
            type: CodeableConcept
            short: Explanation of Adjudication outcome
            binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/adjudication-reason'}
            index: 19
          amount: {type: Money, short: Monetary amount, index: 20}
          value: {type: decimal, short: Non-monetary value, index: 21}
        required: [category]
      detail:
        type: BackboneElement
        short: Detail line items
        array: true
        index: 22
        elements:
          detailSequence: {type: positiveInt, short: Service instance, index: 23}
          noteNumber: {type: positiveInt, short: List of note numbers which apply, array: true, index: 24}
          adjudication:
            short: Detail level adjudication details
            elementReference: ['http://hl7.org/fhir/StructureDefinition/ClaimResponse', elements, item, elements, adjudication]
            array: true
            index: 25
          subDetail:
            type: BackboneElement
            short: Subdetail line items
            array: true
            index: 26
            elements:
              subDetailSequence: {type: positiveInt, short: Service instance, index: 27}
              noteNumber: {type: positiveInt, short: List of note numbers which apply, array: true, index: 28}
              adjudication:
                short: Subdetail level adjudication details
                elementReference: ['http://hl7.org/fhir/StructureDefinition/ClaimResponse', elements, item, elements, adjudication]
                array: true
                index: 29
            required: [subDetailSequence]
        required: [detailSequence]
    required: [itemSequence]
  type:
    short: Type or discipline
    type: CodeableConcept
    binding: {strength: extensible, valueSet: 'http://hl7.org/fhir/ValueSet/claim-type'}
    index: 2
  created: {type: dateTime, short: Creation date, index: 6}
  outcome:
    type: code
    short: queued | complete | error | partial
    binding: {strength: required, valueSet: 'http://hl7.org/fhir/ValueSet/remittance-outcome'}
    index: 10
  disposition: {type: string, short: Disposition Message, index: 11}
  communicationRequest:
    type: Reference
    short: Request for additional information
    refers: ['http://hl7.org/fhir/StructureDefinition/CommunicationRequest']
    array: true
    index: 95
  total:
    type: BackboneElement
    short: Adjudication totals
    array: true
    index: 78
    elements:
      category:
        type: CodeableConcept
        short: Adjudication category such as submitted, co-pay, eligible, benefit, etc.
        binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/adjudication'}
        index: 79
      amount: {type: Money, short: Monetary amount, index: 80}
    required: [amount, category]
  insurer:
    short: Insurance issuing organization
    refers: ['http://hl7.org/fhir/StructureDefinition/Organization']
    type: Reference
    index: 7
  status:
    isModifier: true
    short: active | cancelled | draft | entered-in-error
    type: code
    binding: {strength: required, valueSet: 'http://hl7.org/fhir/ValueSet/fm-status'}
    isModifierReason: 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
    isSummary: true
    index: 1
  identifier: {type: Identifier, short: Response  number, array: true, index: 0}
  reserved:
    type: Coding
    short: Funds reserved status
    binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/fundsreserve'}
    index: 88
  error:
    type: BackboneElement
    short: Processing errors
    array: true
    index: 73
    elements:
      itemSequence: {type: positiveInt, short: Item sequence number, index: 74}
      detailSequence: {type: positiveInt, short: Detail sequence number, index: 75}
      subDetailSequence: {type: positiveInt, short: Subdetail sequence number, index: 76}
      code:
        type: CodeableConcept
        short: Error code detailing processing issues
        binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/adjudication-error'}
        index: 77
    required: [code]
  form:
    type: CodeableConcept
    short: Printed Form Identifier
    binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/forms'}
    index: 89
  subType:
    short: Finer grained claim type information
    type: CodeableConcept
    binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/claim-subtype'}
    index: 3
  addItem:
    type: BackboneElement
    short: Insurer added line items
    array: true
    index: 30
    elements:
      locationAddress: {short: Place of service, type: Address, choiceOf: location, index: 45}
      modifier:
        short: Service/Product billing modifiers
        type: CodeableConcept
        array: true
        binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/claim-modifiers'}
        index: 36
      adjudication:
        short: Added items adjudication
        elementReference: ['http://hl7.org/fhir/StructureDefinition/ClaimResponse', elements, item, elements, adjudication]
        array: true
        index: 54
      subdetailSequence: {type: positiveInt, short: Subdetail sequence number, array: true, index: 33}
      locationCodeableConcept: {short: Place of service, type: CodeableConcept, choiceOf: location, index: 44}
      itemSequence: {type: positiveInt, short: Service instances, array: true, index: 31}
      net: {short: Total item cost, type: Money, index: 50}
      serviced:
        short: Date or dates of Service
        choices: [servicedDate, servicedPeriod]
        index: 39
      detailSequence: {type: positiveInt, short: Detail sequence number, array: true, index: 32}
      subSite:
        type: CodeableConcept
        short: Service Sub-location
        binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/surface'}
        array: true
        index: 52
      locationReference:
        short: Place of service
        refers: ['http://hl7.org/fhir/StructureDefinition/Location']
        type: Reference
        choiceOf: location
        index: 46
      programCode:
        short: Program specific reason for item inclusion
        type: CodeableConcept
        array: true
        binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/ex-program-code'}
        index: 37
      factor: {type: decimal, short: Price scaling factor, index: 49}
      servicedDate: {short: Date or dates of Service, type: date, choiceOf: serviced, index: 40}
      bodySite:
        type: CodeableConcept
        short: Service Location
        binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/tooth'}
        index: 51
      quantity: {type: Quantity, short: Count of Products or Services, index: 47}
      billcode:
        type: CodeableConcept
        short: Group, Service or Product
        binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/service-uscls'}
        index: 35
      location:
        short: Place of service
        choices: [locationCodeableConcept, locationAddress, locationReference]
        index: 43
      provider:
        short: Authorized providers
        refers: ['http://hl7.org/fhir/StructureDefinition/Organization', 'http://hl7.org/fhir/StructureDefinition/Practitioner', 'http://hl7.org/fhir/StructureDefinition/PractitionerRole']
        type: Reference
        array: true
        index: 34
      noteNumber: {type: positiveInt, short: List of note numbers which apply, array: true, index: 53}
      unitPrice: {type: Money, short: 'Fee, charge or cost per point', index: 48}
      servicedPeriod: {short: Date or dates of Service, type: Period, choiceOf: serviced, index: 41}
      detail:
        type: BackboneElement
        short: Insurer added line items
        array: true
        index: 55
        elements:
          modifier:
            short: Service/Product billing modifiers
            type: CodeableConcept
            array: true
            binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/claim-modifiers'}
            index: 57
          adjudication:
            short: Added items detail adjudication
            elementReference: ['http://hl7.org/fhir/StructureDefinition/ClaimResponse', elements, item, elements, adjudication]
            array: true
            index: 63
          net: {short: Total item cost, type: Money, index: 61}
          factor: {type: decimal, short: Price scaling factor, index: 60}
          subDetail:
            type: BackboneElement
            short: Insurer added line items
            array: true
            index: 64
            elements:
              billcode:
                type: CodeableConcept
                short: Group, Service or Product
                binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/service-uscls'}
                index: 65
              modifier:
                short: Service/Product billing modifiers
                type: CodeableConcept
                array: true
                binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/claim-modifiers'}
                index: 66
              quantity: {type: Quantity, short: Count of Products or Services, index: 67}
              unitPrice: {type: Money, short: 'Fee, charge or cost per point', index: 68}
              factor: {type: decimal, short: Price scaling factor, index: 69}
              net: {short: Total item cost, type: Money, index: 70}
              noteNumber: {type: positiveInt, short: List of note numbers which apply, array: true, index: 71}
              adjudication:
                short: Added items detail adjudication
                elementReference: ['http://hl7.org/fhir/StructureDefinition/ClaimResponse', elements, item, elements, adjudication]
                array: true
                index: 72
          quantity: {type: Quantity, short: Count of Products or Services, index: 58}
          billcode:
            type: CodeableConcept
            short: Group, Service or Product
            binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/service-uscls'}
            index: 56
          noteNumber: {type: positiveInt, short: List of note numbers which apply, array: true, index: 62}
          unitPrice: {type: Money, short: 'Fee, charge or cost per point', index: 59}
package_version: 3.5.0
class: resource
kind: resource
url: http://hl7.org/fhir/StructureDefinition/ClaimResponse
base: http://hl7.org/fhir/StructureDefinition/DomainResource
version: null