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: 2
  requestOrganization:
    short: Responsible organization
    refers: ['http://hl7.org/fhir/StructureDefinition/Organization']
    type: Reference
    index: 6
  payeeType: {type: CodeableConcept, short: Party to be paid any benefits payable, index: 10}
  insurance:
    short: Insurance or medical plan
    type: BackboneElement
    array: true
    index: 59
    elements:
      sequence: {type: positiveInt, short: Service instance identifier, index: 60}
      focal: {type: boolean, short: Is the focal Coverage, index: 61}
      coverage:
        short: Insurance information
        refers: ['http://hl7.org/fhir/StructureDefinition/Coverage']
        type: Reference
        index: 62
      businessArrangement: {type: string, short: Business agreement, index: 63}
      preAuthRef: {type: string, short: Pre-Authorization/Determination Reference, array: true, index: 64}
      claimResponse:
        short: Adjudication results
        refers: ['http://hl7.org/fhir/StructureDefinition/ClaimResponse']
        type: Reference
        index: 65
    required: [coverage, focal, sequence]
  request:
    short: Id of resource triggering adjudication
    refers: ['http://hl7.org/fhir/StructureDefinition/Claim']
    type: Reference
    index: 7
  requestProvider:
    short: Responsible practitioner
    refers: ['http://hl7.org/fhir/StructureDefinition/Practitioner']
    type: Reference
    index: 5
  processNote:
    type: BackboneElement
    short: Processing notes
    array: true
    index: 53
    elements:
      number: {type: positiveInt, short: Sequence Number for this note, index: 54}
      type: {type: code, short: display | print | printoper, index: 55}
      text: {type: string, short: Note explanatory text, index: 56}
      language: {type: CodeableConcept, short: Language if different from the resource, index: 57}
  payment:
    type: BackboneElement
    short: Payment details, if paid
    index: 44
    elements:
      type: {type: CodeableConcept, short: Partial or Complete, index: 45}
      adjustment: {type: Money, short: Payment adjustment for non-Claim issues, index: 46}
      adjustmentReason: {type: CodeableConcept, short: Explanation for the non-claim adjustment, index: 47}
      date: {type: date, short: Expected data of Payment, index: 48}
      amount: {type: Money, short: Payable amount after adjustment, index: 49}
      identifier: {type: Identifier, short: Identifier of the payment instrument, index: 50}
  item:
    type: BackboneElement
    short: Line items
    array: true
    index: 11
    elements:
      itemSequence: {type: positiveInt, short: Service instance, index: 12}
      noteNumber: {type: positiveInt, short: List of note numbers which apply, array: true, index: 13}
      adjudication:
        type: BackboneElement
        short: Adjudication details
        array: true
        index: 14
        elements:
          category: {type: CodeableConcept, short: 'Adjudication category such as co-pay, eligible, benefit, etc.', index: 15}
          reason: {type: CodeableConcept, short: Explanation of Adjudication outcome, index: 16}
          amount: {type: Money, short: Monetary amount, index: 17}
          value: {type: decimal, short: Non-monetary value, index: 18}
        required: [category]
      detail:
        type: BackboneElement
        short: Detail line items
        array: true
        index: 19
        elements:
          detailSequence: {type: positiveInt, short: Service instance, index: 20}
          noteNumber: {type: positiveInt, short: List of note numbers which apply, array: true, index: 21}
          adjudication:
            short: Detail level adjudication details
            elementReference: ['http://hl7.org/fhir/StructureDefinition/ClaimResponse', elements, item, elements, adjudication]
            array: true
            index: 22
          subDetail:
            type: BackboneElement
            short: Subdetail line items
            array: true
            index: 23
            elements:
              subDetailSequence: {type: positiveInt, short: Service instance, index: 24}
              noteNumber: {type: positiveInt, short: List of note numbers which apply, array: true, index: 25}
              adjudication:
                short: Subdetail level adjudication details
                elementReference: ['http://hl7.org/fhir/StructureDefinition/ClaimResponse', elements, item, elements, adjudication]
                array: true
                index: 26
            required: [subDetailSequence]
        required: [detailSequence]
    required: [itemSequence]
  created: {type: dateTime, short: Creation date, index: 3}
  outcome: {type: code, short: complete | error | partial, index: 8}
  totalBenefit: {type: Money, short: Total benefit payable for the Claim, index: 43}
  unallocDeductable: {type: Money, short: Unallocated deductible, index: 42}
  disposition: {type: string, short: Disposition Message, index: 9}
  communicationRequest:
    type: Reference
    short: Request for additional information
    refers: ['http://hl7.org/fhir/StructureDefinition/CommunicationRequest']
    array: true
    index: 58
  insurer:
    short: Insurance issuing organization
    refers: ['http://hl7.org/fhir/StructureDefinition/Organization']
    type: Reference
    index: 4
  status: {isModifier: true, short: active | cancelled | draft | entered-in-error, type: code, isSummary: true, index: 1}
  identifier: {type: Identifier, short: Response  number, array: true, index: 0}
  reserved: {type: Coding, short: Funds reserved status, index: 51}
  error:
    type: BackboneElement
    short: Processing errors
    array: true
    index: 36
    elements:
      itemSequence: {type: positiveInt, short: Item sequence number, index: 37}
      detailSequence: {type: positiveInt, short: Detail sequence number, index: 38}
      subDetailSequence: {type: positiveInt, short: Subdetail sequence number, index: 39}
      code: {type: CodeableConcept, short: Error code detailing processing issues, index: 40}
    required: [code]
  form: {type: CodeableConcept, short: Printed Form Identifier, index: 52}
  totalCost: {type: Money, short: Total Cost of service from the Claim, index: 41}
  addItem:
    type: BackboneElement
    short: Insurer added line items
    array: true
    index: 27
    elements:
      itemSequence: {type: positiveInt, short: Service instances, array: true, index: 28}
      detailSequence: {type: positiveInt, short: Detail sequence number, array: true, index: 29}
      subdetailSequence: {type: positiveInt, short: Subdetail sequence number, array: true, index: 30}
      service: {type: CodeableConcept, short: 'Group, Service or Product', index: 31}
      modifier: {short: Service/Product billing modifiers, type: CodeableConcept, array: true, index: 32}
      fee: {type: Money, short: Professional fee or Product charge, index: 33}
      noteNumber: {type: positiveInt, short: List of note numbers which apply, array: true, index: 34}
      adjudication:
        short: Added items adjudication
        elementReference: ['http://hl7.org/fhir/StructureDefinition/ClaimResponse', elements, item, elements, adjudication]
        array: true
        index: 35
package_version: 3.2.0
class: resource
kind: resource
url: http://hl7.org/fhir/StructureDefinition/ClaimResponse
base: http://hl7.org/fhir/StructureDefinition/DomainResource
version: null