description: This resource provides the adjudication details from the processing of a Claim resource.
package_name: hl7.fhir.r4.examples
derivation: specialization
name: ClaimResponse
type: ClaimResponse
elements:
  patient:
    short: The recipient of the products and services
    refers: ['http://hl7.org/fhir/StructureDefinition/Patient']
    type: Reference
    isSummary: true
    index: 5
  requestor:
    short: Party responsible for the claim
    refers: ['http://hl7.org/fhir/StructureDefinition/Organization', 'http://hl7.org/fhir/StructureDefinition/Practitioner', 'http://hl7.org/fhir/StructureDefinition/PractitionerRole']
    type: Reference
    index: 8
  payeeType:
    short: Party to be paid any benefits payable
    type: CodeableConcept
    binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/payeetype'}
    index: 14
  insurance:
    short: Patient insurance information
    type: BackboneElement
    array: true
    index: 94
    elements:
      sequence: {type: positiveInt, short: Insurance instance identifier, index: 95}
      focal: {short: Coverage to be used for adjudication, type: boolean, index: 96}
      coverage:
        short: Insurance information
        refers: ['http://hl7.org/fhir/StructureDefinition/Coverage']
        type: Reference
        index: 97
      businessArrangement: {type: string, short: Additional provider contract number, index: 98}
      claimResponse:
        short: Adjudication results
        refers: ['http://hl7.org/fhir/StructureDefinition/ClaimResponse']
        type: Reference
        index: 99
    required: [coverage, focal, sequence]
  request:
    short: Id of resource triggering adjudication
    refers: ['http://hl7.org/fhir/StructureDefinition/Claim']
    type: Reference
    isSummary: true
    index: 9
  processNote:
    short: Note concerning adjudication
    type: BackboneElement
    array: true
    index: 88
    elements:
      number: {type: positiveInt, short: Note instance identifier, index: 89}
      type:
        short: display | print | printoper
        type: code
        binding: {strength: required, valueSet: 'http://hl7.org/fhir/ValueSet/note-type|4.0.1'}
        index: 90
      text: {type: string, short: Note explanatory text, index: 91}
      language:
        short: Language of the text
        type: CodeableConcept
        binding: {strength: preferred, valueSet: 'http://hl7.org/fhir/ValueSet/languages'}
        index: 92
    required: [text]
  preAuthRef: {short: Preauthorization reference, type: string, index: 12}
  adjudication:
    short: Header-level adjudication
    elementReference: ['http://hl7.org/fhir/StructureDefinition/ClaimResponse', elements, item, elements, adjudication]
    array: true
    index: 74
  use:
    short: claim | preauthorization | predetermination
    type: code
    binding: {strength: required, valueSet: 'http://hl7.org/fhir/ValueSet/claim-use|4.0.1'}
    isSummary: true
    index: 4
  payment:
    short: Payment Details
    type: BackboneElement
    index: 78
    elements:
      type:
        short: Partial or complete payment
        type: CodeableConcept
        binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/ex-paymenttype'}
        index: 79
      adjustment: {short: Payment adjustment for non-claim issues, type: Money, index: 80}
      adjustmentReason:
        short: Explanation for the adjustment
        type: CodeableConcept
        binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/payment-adjustment-reason'}
        index: 81
      date: {type: date, short: Expected date of payment, index: 82}
      amount: {type: Money, short: Payable amount after adjustment, index: 83}
      identifier: {short: Business identifier for the payment, type: Identifier, index: 84}
    required: [type, amount]
  item:
    short: Adjudication for claim line items
    type: BackboneElement
    array: true
    index: 15
    elements:
      itemSequence: {type: positiveInt, short: Claim item instance identifier, index: 16}
      noteNumber: {type: positiveInt, short: Applicable note numbers, array: true, index: 17}
      adjudication:
        min: 1
        short: Adjudication details
        type: BackboneElement
        array: true
        index: 18
        elements:
          category:
            short: Type of adjudication information
            type: CodeableConcept
            binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/adjudication'}
            index: 19
          reason:
            short: Explanation of adjudication outcome
            type: CodeableConcept
            binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/adjudication-reason'}
            index: 20
          amount: {short: Monetary amount, type: Money, index: 21}
          value: {short: Non-monetary value, type: decimal, index: 22}
        required: [category]
      detail:
        short: Adjudication for claim details
        type: BackboneElement
        array: true
        index: 23
        elements:
          detailSequence: {type: positiveInt, short: Claim detail instance identifier, index: 24}
          noteNumber: {type: positiveInt, short: Applicable note numbers, array: true, index: 25}
          adjudication:
            short: Detail level adjudication details
            elementReference: ['http://hl7.org/fhir/StructureDefinition/ClaimResponse', elements, item, elements, adjudication]
            array: true
            min: 1
            index: 26
          subDetail:
            short: Adjudication for claim sub-details
            type: BackboneElement
            array: true
            index: 27
            elements:
              subDetailSequence: {type: positiveInt, short: Claim sub-detail instance identifier, index: 28}
              noteNumber: {type: positiveInt, short: Applicable note numbers, array: true, index: 29}
              adjudication:
                short: Subdetail level adjudication details
                elementReference: ['http://hl7.org/fhir/StructureDefinition/ClaimResponse', elements, item, elements, adjudication]
                array: true
                index: 30
            required: [subDetailSequence]
        required: [adjudication, detailSequence]
    required: [adjudication, itemSequence]
  type:
    short: More granular claim type
    type: CodeableConcept
    binding: {strength: extensible, valueSet: 'http://hl7.org/fhir/ValueSet/claim-type'}
    isSummary: true
    index: 2
  created: {short: Response creation date, type: dateTime, isSummary: true, index: 6}
  preAuthPeriod: {type: Period, short: Preauthorization reference effective period, index: 13}
  outcome:
    short: queued | complete | error | partial
    type: code
    binding: {strength: required, valueSet: 'http://hl7.org/fhir/ValueSet/remittance-outcome|4.0.1'}
    isSummary: true
    index: 10
  disposition: {short: Disposition Message, type: string, index: 11}
  communicationRequest:
    short: Request for additional information
    refers: ['http://hl7.org/fhir/StructureDefinition/CommunicationRequest']
    type: Reference
    array: true
    index: 93
  total:
    short: Adjudication totals
    type: BackboneElement
    array: true
    isSummary: true
    index: 75
    elements:
      category:
        short: Type of adjudication information
        type: CodeableConcept
        binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/adjudication'}
        isSummary: true
        index: 76
      amount: {short: Financial total for the category, type: Money, isSummary: true, index: 77}
    required: [amount, category]
  insurer:
    short: Party responsible for reimbursement
    refers: ['http://hl7.org/fhir/StructureDefinition/Organization']
    type: Reference
    isSummary: true
    index: 7
  fundsReserve:
    short: Funds reserved status
    type: CodeableConcept
    binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/fundsreserve'}
    index: 85
  status:
    isModifier: true
    short: active | cancelled | draft | entered-in-error
    type: code
    binding: {strength: required, valueSet: 'http://hl7.org/fhir/ValueSet/fm-status|4.0.1'}
    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: {short: Business Identifier for a claim response, type: Identifier, array: true, index: 0}
  error:
    short: Processing errors
    type: BackboneElement
    array: true
    index: 100
    elements:
      itemSequence: {type: positiveInt, short: Item sequence number, index: 101}
      detailSequence: {type: positiveInt, short: Detail sequence number, index: 102}
      subDetailSequence: {type: positiveInt, short: Subdetail sequence number, index: 103}
      code:
        short: Error code detailing processing issues
        type: CodeableConcept
        binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/adjudication-error'}
        index: 104
    required: [code]
  form: {short: Printed reference or actual form, type: Attachment, index: 87}
  subType:
    short: More granular claim type
    type: CodeableConcept
    binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/claim-subtype'}
    index: 3
  formCode:
    short: Printed form identifier
    type: CodeableConcept
    binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/forms'}
    index: 86
  addItem:
    short: Insurer added line items
    type: BackboneElement
    array: true
    index: 31
    elements:
      locationAddress: {short: Place of service or where product was supplied, type: Address, choiceOf: location, index: 46}
      modifier:
        short: Service/Product billing modifiers
        type: CodeableConcept
        array: true
        binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/claim-modifiers'}
        index: 37
      adjudication:
        short: Added items adjudication
        elementReference: ['http://hl7.org/fhir/StructureDefinition/ClaimResponse', elements, item, elements, adjudication]
        array: true
        min: 1
        index: 55
      subdetailSequence: {type: positiveInt, short: Subdetail sequence number, array: true, index: 34}
      locationCodeableConcept: {short: Place of service or where product was supplied, type: CodeableConcept, choiceOf: location, index: 45}
      itemSequence: {type: positiveInt, short: Item sequence number, array: true, index: 32}
      net: {short: Total item cost, type: Money, index: 51}
      serviced:
        short: Date or dates of service or product delivery
        choices: [servicedDate, servicedPeriod]
        index: 40
      detailSequence: {type: positiveInt, short: Detail sequence number, array: true, index: 33}
      subSite:
        short: Anatomical sub-location
        type: CodeableConcept
        array: true
        binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/surface'}
        index: 53
      productOrService:
        short: Billing, service, product, or drug code
        type: CodeableConcept
        binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/service-uscls'}
        index: 36
      locationReference:
        short: Place of service or where product was supplied
        refers: ['http://hl7.org/fhir/StructureDefinition/Location']
        type: Reference
        choiceOf: location
        index: 47
      programCode:
        short: Program the product or service is provided under
        type: CodeableConcept
        array: true
        binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/ex-program-code'}
        index: 38
      factor: {short: Price scaling factor, type: decimal, index: 50}
      servicedDate: {short: Date or dates of service or product delivery, type: date, choiceOf: serviced, index: 41}
      bodySite:
        short: Anatomical location
        type: CodeableConcept
        binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/tooth'}
        index: 52
      quantity: {short: Count of products or services, type: Quantity, index: 48}
      location:
        short: Place of service or where product was supplied
        choices: [locationCodeableConcept, locationAddress, locationReference]
        index: 44
      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: 35
      noteNumber: {type: positiveInt, short: Applicable note numbers, array: true, index: 54}
      unitPrice: {type: Money, short: 'Fee, charge or cost per item', index: 49}
      servicedPeriod: {short: Date or dates of service or product delivery, type: Period, choiceOf: serviced, index: 42}
      detail:
        type: BackboneElement
        short: Insurer added line details
        array: true
        index: 56
        elements:
          modifier:
            short: Service/Product billing modifiers
            type: CodeableConcept
            array: true
            binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/claim-modifiers'}
            index: 58
          adjudication:
            short: Added items detail adjudication
            elementReference: ['http://hl7.org/fhir/StructureDefinition/ClaimResponse', elements, item, elements, adjudication]
            array: true
            min: 1
            index: 64
          net: {short: Total item cost, type: Money, index: 62}
          productOrService:
            short: Billing, service, product, or drug code
            type: CodeableConcept
            binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/service-uscls'}
            index: 57
          factor: {short: Price scaling factor, type: decimal, index: 61}
          subDetail:
            type: BackboneElement
            short: Insurer added line items
            array: true
            index: 65
            elements:
              productOrService:
                short: Billing, service, product, or drug code
                type: CodeableConcept
                binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/service-uscls'}
                index: 66
              modifier:
                short: Service/Product billing modifiers
                type: CodeableConcept
                array: true
                binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/claim-modifiers'}
                index: 67
              quantity: {short: Count of products or services, type: Quantity, index: 68}
              unitPrice: {type: Money, short: 'Fee, charge or cost per item', index: 69}
              factor: {short: Price scaling factor, type: decimal, index: 70}
              net: {short: Total item cost, type: Money, index: 71}
              noteNumber: {type: positiveInt, short: Applicable note numbers, array: true, index: 72}
              adjudication:
                short: Added items detail adjudication
                elementReference: ['http://hl7.org/fhir/StructureDefinition/ClaimResponse', elements, item, elements, adjudication]
                array: true
                min: 1
                index: 73
            required: [adjudication, productOrService]
          quantity: {short: Count of products or services, type: Quantity, index: 59}
          noteNumber: {type: positiveInt, short: Applicable note numbers, array: true, index: 63}
          unitPrice: {type: Money, short: 'Fee, charge or cost per item', index: 60}
        required: [adjudication, productOrService]
    required: [adjudication, productOrService]
package_version: 4.0.1
class: resource
kind: resource
url: http://hl7.org/fhir/StructureDefinition/ClaimResponse
base: http://hl7.org/fhir/StructureDefinition/DomainResource
version: 4.0.1
required: [created, insurer, status, type, patient, use, outcome]