ClaimResponse - FHIR Resource (dstu2)


This ClaimResponse Resource uses the FHIR API standard for access and structure.

Validate an ClaimResponse FHIR Resource (dstu2)



Resource Attributes

AttributeField is listTypeDescription
addItemtrueData Type Insurer added line items
coveragetrueData Type Insurance or medical plan
createdfalsedateTime Creation date
dispositionfalsestring Disposition Message
errortrueData Type Processing errors
formfalseCoding Printed Form Identifier
identifiertrueIdentifier Response number
itemtrueData Type Line items
notetrueData Type Processing notes
organizationfalseReference Insurer
originalRulesetfalseCoding Original version
outcomefalsecode complete | error
payeeTypefalseCoding Party to be paid any benefits payable
paymentAdjustmentfalseQuantity Payment adjustment for non-Claim issues
paymentAdjustmentReasonfalseCoding Reason for Payment adjustment
paymentAmountfalseQuantity Payment amount
paymentDatefalsedate Expected data of Payment
paymentReffalseIdentifier Payment identifier
requestfalseReference Id of resource triggering adjudication
requestOrganizationfalseReference Responsible organization
requestProviderfalseReference Responsible practitioner
reservedfalseCoding Funds reserved status
rulesetfalseCoding Resource version
totalBenefitfalseQuantity Total benefit payable for the Claim
totalCostfalseQuantity Total Cost of service from the Claim
unallocDeductablefalseQuantity Unallocated deductible

ClaimResponse Structure


  
{
  "resourceType" : "ClaimResponse",
  // from Resource: id, meta, implicitRules, and language
  // from DomainResource: text, contained, extension, and modifierExtension
  "identifier" : [{ Identifier }], // Response  number
  "request" : { Reference(Claim) }, // Id of resource triggering adjudication
  "ruleset" : { Coding }, // Resource version
  "originalRuleset" : { Coding }, // Original version
  "created" : "<dateTime>", // Creation date
  "organization" : { Reference(Organization) }, // Insurer
  "requestProvider" : { Reference(Practitioner) }, // Responsible practitioner
  "requestOrganization" : { Reference(Organization) }, // Responsible organization
  "outcome" : "<code>", // complete | error
  "disposition" : "<string>", // Disposition Message
  "payeeType" : { Coding }, // Party to be paid any benefits payable
  "item" : [{ // Line items
    "sequenceLinkId" : "<positiveInt>", // R!  Service instance
    "noteNumber" : ["<positiveInt>"], // List of note numbers which apply
    "adjudication" : [{ // Adjudication details
      "code" : { Coding }, // R!  Adjudication category such as co-pay, eligible, benefit, etc.
      "amount" : { Quantity(Money) }, // Monetary amount
      "value" : <decimal> // Non-monetary value
    }],
    "detail" : [{ // Detail line items
      "sequenceLinkId" : "<positiveInt>", // R!  Service instance
      "adjudication" : [{ // Detail adjudication
        "code" : { Coding }, // R!  Adjudication category such as co-pay, eligible, benefit, etc.
        "amount" : { Quantity(Money) }, // Monetary amount
        "value" : <decimal> // Non-monetary value
      }],
      "subDetail" : [{ // Subdetail line items
        "sequenceLinkId" : "<positiveInt>", // R!  Service instance
        "adjudication" : [{ // Subdetail adjudication
          "code" : { Coding }, // R!  Adjudication category such as co-pay, eligible, benefit, etc.
          "amount" : { Quantity(Money) }, // Monetary amount
          "value" : <decimal> // Non-monetary value
        }]
      }]
    }]
  }],
  "addItem" : [{ // Insurer added line items
    "sequenceLinkId" : ["<positiveInt>"], // Service instances
    "service" : { Coding }, // R!  Group, Service or Product
    "fee" : { Quantity(Money) }, // Professional fee or Product charge
    "noteNumberLinkId" : ["<positiveInt>"], // List of note numbers which apply
    "adjudication" : [{ // Added items adjudication
      "code" : { Coding }, // R!  Adjudication category such as co-pay, eligible, benefit, etc.
      "amount" : { Quantity(Money) }, // Monetary amount
      "value" : <decimal> // Non-monetary value
    }],
    "detail" : [{ // Added items details
      "service" : { Coding }, // R!  Service or Product
      "fee" : { Quantity(Money) }, // Professional fee or Product charge
      "adjudication" : [{ // Added items detail adjudication
        "code" : { Coding }, // R!  Adjudication category such as co-pay, eligible, benefit, etc.
        "amount" : { Quantity(Money) }, // Monetary amount
        "value" : <decimal> // Non-monetary value
      }]
    }]
  }],
  "error" : [{ // Processing errors
    "sequenceLinkId" : "<positiveInt>", // Item sequence number
    "detailSequenceLinkId" : "<positiveInt>", // Detail sequence number
    "subdetailSequenceLinkId" : "<positiveInt>", // Subdetail sequence number
    "code" : { Coding } // R!  Error code detailing processing issues
  }],
  "totalCost" : { Quantity(Money) }, // Total Cost of service from the Claim
  "unallocDeductable" : { Quantity(Money) }, // Unallocated deductible
  "totalBenefit" : { Quantity(Money) }, // Total benefit payable for the Claim
  "paymentAdjustment" : { Quantity(Money) }, // Payment adjustment for non-Claim issues
  "paymentAdjustmentReason" : { Coding }, // Reason for Payment adjustment
  "paymentDate" : "<date>", // Expected data of Payment
  "paymentAmount" : { Quantity(Money) }, // Payment amount
  "paymentRef" : { Identifier }, // Payment identifier
  "reserved" : { Coding }, // Funds reserved status
  "form" : { Coding }, // Printed Form Identifier
  "note" : [{ // Processing notes
    "number" : "<positiveInt>", // Note Number for this note
    "type" : { Coding }, // display | print | printoper
    "text" : "<string>" // Note explanatory text
  }],
  "coverage" : [{ // Insurance or medical plan
    "sequence" : "<positiveInt>", // R!  Service instance identifier
    "focal" : <boolean>, // R!  Is the focal Coverage
    "coverage" : { Reference(Coverage) }, // R!  Insurance information
    "businessArrangement" : "<string>", // Business agreement
    "relationship" : { Coding }, // R!  Patient relationship to subscriber
    "preAuthRef" : ["<string>"], // Pre-Authorization/Determination Reference
    "claimResponse" : { Reference(ClaimResponse) }, // Adjudication results
    "originalRuleset" : { Coding } // Original version
  }]
}


 

ClaimResponse Search Parameters

The following search parameters can be used to query ClaimResponse resources. Just submit the like so:

https://api.1up.health/fhir/dstu2/ClaimResponse?query-param=queryvalue
Search ParameterField TypeResource Fields Searched
identifiertextidentifier