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