description: This resource provides the adjudication details from the processing of a Claim resource. package_name: hl7.fhir.r5.core derivation: specialization name: ClaimResponse type: ClaimResponse elements: patient: isModifier: false short: The recipient of the products and services refers: ['http://hl7.org/fhir/StructureDefinition/Patient'] type: Reference mustSupport: false isSummary: true index: 5 requestor: isModifier: false 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 mustSupport: false isSummary: false index: 8 payeeType: isModifier: false short: Party to be paid any benefits payable type: CodeableConcept mustSupport: false binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/payeetype'} isSummary: false index: 15 insurance: isModifier: false short: Patient insurance information index: 113 type: BackboneElement mustSupport: false array: true elements: sequence: {isModifier: false, short: Insurance instance identifier, type: positiveInt, mustSupport: false, isSummary: false, index: 114} focal: {isModifier: false, short: Coverage to be used for adjudication, type: boolean, mustSupport: false, isSummary: false, index: 115} coverage: isModifier: false short: Insurance information refers: ['http://hl7.org/fhir/StructureDefinition/Coverage'] type: Reference mustSupport: false isSummary: false index: 116 businessArrangement: {isModifier: false, short: Additional provider contract number, type: string, mustSupport: false, isSummary: false, index: 117} claimResponse: isModifier: false short: Adjudication results refers: ['http://hl7.org/fhir/StructureDefinition/ClaimResponse'] type: Reference mustSupport: false isSummary: false index: 118 required: [coverage, focal, sequence] isSummary: false request: isModifier: false short: Id of resource triggering adjudication refers: ['http://hl7.org/fhir/StructureDefinition/Claim'] type: Reference mustSupport: false isSummary: true index: 9 processNote: isModifier: false short: Note concerning adjudication index: 107 type: BackboneElement mustSupport: false array: true elements: number: {isModifier: false, short: Note instance identifier, type: positiveInt, mustSupport: false, isSummary: false, index: 108} type: isModifier: false short: display | print | printoper type: code mustSupport: false binding: {strength: required, valueSet: 'http://hl7.org/fhir/ValueSet/note-type|5.0.0-snapshot3'} isSummary: false index: 109 text: {isModifier: false, short: Note explanatory text, type: string, mustSupport: false, isSummary: false, index: 110} language: isModifier: false short: Language of the text type: CodeableConcept mustSupport: false binding: {strength: preferred, valueSet: 'http://hl7.org/fhir/ValueSet/languages'} isSummary: false index: 111 required: [text] isSummary: false preAuthRef: {isModifier: false, short: Preauthorization reference, type: string, mustSupport: false, isSummary: false, index: 13} adjudication: elementReference: ['http://hl7.org/fhir/StructureDefinition/ClaimResponse', elements, item, elements, adjudication] isModifier: false short: Header-level adjudication mustSupport: false array: true isSummary: false index: 93 encounter: isModifier: false short: Encounters related to this billed item refers: ['http://hl7.org/fhir/StructureDefinition/Encounter'] type: Reference mustSupport: false array: true isSummary: false index: 16 use: isModifier: false short: claim | preauthorization | predetermination type: code mustSupport: false binding: {strength: required, valueSet: 'http://hl7.org/fhir/ValueSet/claim-use|5.0.0-snapshot3'} isSummary: true index: 4 payment: isModifier: false short: Payment Details type: BackboneElement mustSupport: false isSummary: false index: 97 elements: type: isModifier: false short: Partial or complete payment type: CodeableConcept mustSupport: false binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/ex-paymenttype'} isSummary: false index: 98 adjustment: {isModifier: false, short: Payment adjustment for non-claim issues, type: Money, mustSupport: false, isSummary: false, index: 99} adjustmentReason: isModifier: false short: Explanation for the adjustment type: CodeableConcept mustSupport: false binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/payment-adjustment-reason'} isSummary: false index: 100 date: {isModifier: false, short: Expected date of payment, type: date, mustSupport: false, isSummary: false, index: 101} amount: {isModifier: false, short: Payable amount after adjustment, type: Money, mustSupport: false, isSummary: false, index: 102} identifier: {isModifier: false, short: Business identifier for the payment, type: Identifier, mustSupport: false, isSummary: false, index: 103} required: [type, amount] item: isModifier: false short: Adjudication for claim line items index: 18 type: BackboneElement mustSupport: false array: true elements: itemSequence: {isModifier: false, short: Claim item instance identifier, type: positiveInt, mustSupport: false, isSummary: false, index: 19} noteNumber: {isModifier: false, short: Applicable note numbers, type: positiveInt, mustSupport: false, array: true, isSummary: false, index: 20} decision: isModifier: false short: Result of the adjudication type: CodeableConcept mustSupport: false binding: {strength: required, valueSet: 'http://hl7.org/fhir/ValueSet/claim-decision|5.0.0-snapshot3'} isSummary: false index: 21 adjudication: isModifier: false short: Adjudication details index: 22 type: BackboneElement mustSupport: false array: true elements: category: isModifier: false short: Type of adjudication information type: CodeableConcept mustSupport: false binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/adjudication'} isSummary: false index: 23 reason: isModifier: false short: Explanation of adjudication outcome type: CodeableConcept mustSupport: false binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/adjudication-reason'} isSummary: false index: 24 amount: {isModifier: false, short: Monetary amount, type: Money, mustSupport: false, isSummary: false, index: 25} value: {isModifier: false, short: Non-monetary value, type: decimal, mustSupport: false, isSummary: false, index: 26} required: [category] isSummary: false detail: isModifier: false short: Adjudication for claim details index: 27 type: BackboneElement mustSupport: false array: true elements: detailSequence: {isModifier: false, short: Claim detail instance identifier, type: positiveInt, mustSupport: false, isSummary: false, index: 28} noteNumber: {isModifier: false, short: Applicable note numbers, type: positiveInt, mustSupport: false, array: true, isSummary: false, index: 29} decision: isModifier: false short: Result of the adjudication type: CodeableConcept mustSupport: false binding: {strength: required, valueSet: 'http://hl7.org/fhir/ValueSet/claim-decision|5.0.0-snapshot3'} isSummary: false index: 30 adjudication: elementReference: ['http://hl7.org/fhir/StructureDefinition/ClaimResponse', elements, item, elements, adjudication] isModifier: false short: Detail level adjudication details mustSupport: false array: true isSummary: false index: 31 subDetail: isModifier: false short: Adjudication for claim sub-details index: 32 type: BackboneElement mustSupport: false array: true elements: subDetailSequence: {isModifier: false, short: Claim sub-detail instance identifier, type: positiveInt, mustSupport: false, isSummary: false, index: 33} noteNumber: {isModifier: false, short: Applicable note numbers, type: positiveInt, mustSupport: false, array: true, isSummary: false, index: 34} decision: isModifier: false short: Result of the adjudication type: CodeableConcept mustSupport: false binding: {strength: required, valueSet: 'http://hl7.org/fhir/ValueSet/claim-decision|5.0.0-snapshot3'} isSummary: false index: 35 adjudication: elementReference: ['http://hl7.org/fhir/StructureDefinition/ClaimResponse', elements, item, elements, adjudication] isModifier: false short: Subdetail level adjudication details mustSupport: false array: true isSummary: false index: 36 required: [subDetailSequence] isSummary: false required: [detailSequence] isSummary: false required: [itemSequence] isSummary: false type: isModifier: false short: More granular claim type type: CodeableConcept mustSupport: false binding: {strength: extensible, valueSet: 'http://hl7.org/fhir/ValueSet/claim-type'} isSummary: true index: 2 created: {isModifier: false, short: Response creation date, type: dateTime, mustSupport: false, isSummary: true, index: 6} preAuthPeriod: {isModifier: false, short: Preauthorization reference effective period, type: Period, mustSupport: false, isSummary: false, index: 14} outcome: isModifier: false short: queued | complete | error | partial type: code mustSupport: false binding: {strength: required, valueSet: 'http://hl7.org/fhir/ValueSet/claim-outcome|5.0.0-snapshot3'} isSummary: true index: 10 disposition: {isModifier: false, short: Disposition Message, type: string, mustSupport: false, isSummary: false, index: 12} communicationRequest: isModifier: false short: Request for additional information refers: ['http://hl7.org/fhir/StructureDefinition/CommunicationRequest'] type: Reference mustSupport: false array: true isSummary: false index: 112 diagnosisRelatedGroup: isModifier: false short: Package billing code type: CodeableConcept mustSupport: false binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/ex-diagnosisrelatedgroup'} isSummary: false index: 17 total: isModifier: false short: Adjudication totals index: 94 type: BackboneElement mustSupport: false array: true elements: category: isModifier: false short: Type of adjudication information type: CodeableConcept mustSupport: false binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/adjudication'} isSummary: true index: 95 amount: {isModifier: false, short: Financial total for the category, type: Money, mustSupport: false, isSummary: true, index: 96} required: [amount, category] isSummary: true insurer: isModifier: false short: Party responsible for reimbursement refers: ['http://hl7.org/fhir/StructureDefinition/Organization'] type: Reference mustSupport: false isSummary: true index: 7 fundsReserve: isModifier: false short: Funds reserved status type: CodeableConcept mustSupport: false binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/fundsreserve'} isSummary: false index: 104 status: isModifier: true short: active | cancelled | draft | entered-in-error index: 1 type: code mustSupport: false binding: {strength: required, valueSet: 'http://hl7.org/fhir/ValueSet/fm-status|5.0.0-snapshot3'} 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 identifier: {isModifier: false, short: Business Identifier for a claim response, type: Identifier, mustSupport: false, array: true, isSummary: false, index: 0} error: isModifier: false short: Processing errors index: 119 type: BackboneElement mustSupport: false array: true elements: itemSequence: {isModifier: false, short: Item sequence number, type: positiveInt, mustSupport: false, isSummary: false, index: 120} detailSequence: {isModifier: false, short: Detail sequence number, type: positiveInt, mustSupport: false, isSummary: false, index: 121} subDetailSequence: {isModifier: false, short: Subdetail sequence number, type: positiveInt, mustSupport: false, isSummary: false, index: 122} code: isModifier: false short: Error code detailing processing issues type: CodeableConcept mustSupport: false binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/adjudication-error'} isSummary: false index: 123 required: [code] isSummary: false form: {isModifier: false, short: Printed reference or actual form, type: Attachment, mustSupport: false, isSummary: false, index: 106} subType: isModifier: false short: More granular claim type type: CodeableConcept mustSupport: false binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/claim-subtype'} isSummary: false index: 3 formCode: isModifier: false short: Printed form identifier type: CodeableConcept mustSupport: false binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/forms'} isSummary: false index: 105 addItem: isModifier: false short: Insurer added line items type: BackboneElement mustSupport: false array: true isSummary: false index: 37 elements: locationAddress: {isModifier: false, short: Place of service or where product was supplied, type: Address, mustSupport: false, choiceOf: location, isSummary: false, index: 54} modifier: isModifier: false short: Service/Product billing modifiers type: CodeableConcept mustSupport: false array: true binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/claim-modifiers'} isSummary: false index: 45 revenue: isModifier: false short: Revenue or cost center code type: CodeableConcept mustSupport: false binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/ex-revenue-center'} isSummary: false index: 42 adjudication: elementReference: ['http://hl7.org/fhir/StructureDefinition/ClaimResponse', elements, item, elements, adjudication] isModifier: false short: Added items adjudication mustSupport: false array: true isSummary: false index: 66 subdetailSequence: {isModifier: false, short: Subdetail sequence number, type: positiveInt, mustSupport: false, array: true, isSummary: false, index: 40} productOrServiceEnd: isModifier: false short: End of a range of codes type: CodeableConcept mustSupport: false binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/service-uscls'} isSummary: false index: 44 locationCodeableConcept: {isModifier: false, short: Place of service or where product was supplied, type: CodeableConcept, mustSupport: false, choiceOf: location, isSummary: false, index: 53} itemSequence: {isModifier: false, short: Item sequence number, type: positiveInt, mustSupport: false, array: true, isSummary: false, index: 38} net: {isModifier: false, short: Total item cost, type: Money, mustSupport: false, isSummary: false, index: 60} serviced: isModifier: false short: Date or dates of service or product delivery mustSupport: false choices: [servicedDate, servicedPeriod] isSummary: false index: 48 detailSequence: {isModifier: false, short: Detail sequence number, type: positiveInt, mustSupport: false, array: true, isSummary: false, index: 39} tax: {isModifier: false, short: Total tax, type: Money, mustSupport: false, isSummary: false, index: 59} productOrService: isModifier: false short: Billing, service, product, or drug code type: CodeableConcept mustSupport: false binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/service-uscls'} isSummary: false index: 43 locationReference: isModifier: false short: Place of service or where product was supplied refers: ['http://hl7.org/fhir/StructureDefinition/Location'] type: Reference mustSupport: false choiceOf: location isSummary: false index: 55 programCode: isModifier: false short: Program the product or service is provided under type: CodeableConcept mustSupport: false array: true binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/ex-program-code'} isSummary: false index: 46 factor: {isModifier: false, short: Price scaling factor, type: decimal, mustSupport: false, isSummary: false, index: 58} servicedDate: {isModifier: false, short: Date or dates of service or product delivery, type: date, mustSupport: false, choiceOf: serviced, isSummary: false, index: 49} bodySite: isModifier: false short: Anatomical location index: 61 type: BackboneElement mustSupport: false array: true elements: site: min: 1 isModifier: false short: Location index: 62 type: CodeableReference mustSupport: false array: true binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/tooth'} isSummary: false subSite: isModifier: false short: Sub-location type: CodeableConcept mustSupport: false array: true binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/surface'} isSummary: false index: 63 required: [site] isSummary: false quantity: {isModifier: false, short: Count of products or services, type: Quantity, mustSupport: false, isSummary: false, index: 56} location: isModifier: false short: Place of service or where product was supplied mustSupport: false choices: [locationCodeableConcept, locationAddress, locationReference] isSummary: false index: 52 provider: isModifier: false short: Authorized providers refers: ['http://hl7.org/fhir/StructureDefinition/Organization', 'http://hl7.org/fhir/StructureDefinition/Practitioner', 'http://hl7.org/fhir/StructureDefinition/PractitionerRole'] type: Reference mustSupport: false array: true isSummary: false index: 41 noteNumber: {isModifier: false, short: Applicable note numbers, type: positiveInt, mustSupport: false, array: true, isSummary: false, index: 64} unitPrice: {isModifier: false, short: 'Fee, charge or cost per item', type: Money, mustSupport: false, isSummary: false, index: 57} decision: isModifier: false short: Result of the adjudication type: CodeableConcept mustSupport: false binding: {strength: required, valueSet: 'http://hl7.org/fhir/ValueSet/claim-decision|5.0.0-snapshot3'} isSummary: false index: 65 servicedPeriod: {isModifier: false, short: Date or dates of service or product delivery, type: Period, mustSupport: false, choiceOf: serviced, isSummary: false, index: 50} detail: isModifier: false short: Insurer added line details type: BackboneElement mustSupport: false array: true isSummary: false index: 67 elements: modifier: isModifier: false short: Service/Product billing modifiers type: CodeableConcept mustSupport: false array: true binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/claim-modifiers'} isSummary: false index: 71 revenue: isModifier: false short: Revenue or cost center code type: CodeableConcept mustSupport: false binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/ex-revenue-center'} isSummary: false index: 68 adjudication: elementReference: ['http://hl7.org/fhir/StructureDefinition/ClaimResponse', elements, item, elements, adjudication] isModifier: false short: Added items detail adjudication mustSupport: false array: true isSummary: false index: 79 productOrServiceEnd: isModifier: false short: End of a range of codes type: CodeableConcept mustSupport: false binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/service-uscls'} isSummary: false index: 70 net: {isModifier: false, short: Total item cost, type: Money, mustSupport: false, isSummary: false, index: 76} tax: {isModifier: false, short: Total tax, type: Money, mustSupport: false, isSummary: false, index: 75} productOrService: isModifier: false short: Billing, service, product, or drug code type: CodeableConcept mustSupport: false binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/service-uscls'} isSummary: false index: 69 factor: {isModifier: false, short: Price scaling factor, type: decimal, mustSupport: false, isSummary: false, index: 74} subDetail: isModifier: false short: Insurer added line items type: BackboneElement mustSupport: false array: true isSummary: false index: 80 elements: modifier: isModifier: false short: Service/Product billing modifiers type: CodeableConcept mustSupport: false array: true binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/claim-modifiers'} isSummary: false index: 84 revenue: isModifier: false short: Revenue or cost center code type: CodeableConcept mustSupport: false binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/ex-revenue-center'} isSummary: false index: 81 adjudication: elementReference: ['http://hl7.org/fhir/StructureDefinition/ClaimResponse', elements, item, elements, adjudication] isModifier: false short: Added items detail adjudication mustSupport: false array: true isSummary: false index: 92 productOrServiceEnd: isModifier: false short: End of a range of codes type: CodeableConcept mustSupport: false binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/service-uscls'} isSummary: false index: 83 net: {isModifier: false, short: Total item cost, type: Money, mustSupport: false, isSummary: false, index: 89} tax: {isModifier: false, short: Total tax, type: Money, mustSupport: false, isSummary: false, index: 88} productOrService: isModifier: false short: Billing, service, product, or drug code type: CodeableConcept mustSupport: false binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/service-uscls'} isSummary: false index: 82 factor: {isModifier: false, short: Price scaling factor, type: decimal, mustSupport: false, isSummary: false, index: 87} quantity: {isModifier: false, short: Count of products or services, type: Quantity, mustSupport: false, isSummary: false, index: 85} noteNumber: {isModifier: false, short: Applicable note numbers, type: positiveInt, mustSupport: false, array: true, isSummary: false, index: 90} unitPrice: {isModifier: false, short: 'Fee, charge or cost per item', type: Money, mustSupport: false, isSummary: false, index: 86} decision: isModifier: false short: Result of the adjudication type: CodeableConcept mustSupport: false binding: {strength: required, valueSet: 'http://hl7.org/fhir/ValueSet/claim-decision|5.0.0-snapshot3'} isSummary: false index: 91 quantity: {isModifier: false, short: Count of products or services, type: Quantity, mustSupport: false, isSummary: false, index: 72} noteNumber: {isModifier: false, short: Applicable note numbers, type: positiveInt, mustSupport: false, array: true, isSummary: false, index: 77} unitPrice: {isModifier: false, short: 'Fee, charge or cost per item', type: Money, mustSupport: false, isSummary: false, index: 73} decision: isModifier: false short: Result of the adjudication type: CodeableConcept mustSupport: false binding: {strength: required, valueSet: 'http://hl7.org/fhir/ValueSet/claim-decision|5.0.0-snapshot3'} isSummary: false index: 78 decision: isModifier: false short: Result of the adjudication type: CodeableConcept mustSupport: false binding: {strength: required, valueSet: 'http://hl7.org/fhir/ValueSet/claim-decision|5.0.0-snapshot3'} isSummary: true index: 11 package_version: 5.0.0-snapshot3 class: resource kind: resource url: http://hl7.org/fhir/StructureDefinition/ClaimResponse base: http://hl7.org/fhir/StructureDefinition/DomainResource version: 5.0.0-snapshot3 required: [created, status, type, patient, use, outcome]