ClaimResponse - FHIR Resource (stu3)


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

Validate an ClaimResponse FHIR Resource (stu3)



Resource Attributes

AttributeField is listTypeDescription
addItemtrueData Type# Insurer added line items
communicationRequesttrueReference# Request for additional information
createdfalsedateTime# Creation date
dispositionfalsestring# Disposition Message
errortrueData Type# Processing errors
formfalseCodeableConcept# Printed Form Identifier
identifiertrueIdentifier# Response number
insurancetrueData Type# Insurance or medical plan
insurerfalseReference# Insurance issuing organization
itemtrueData Type# Line items
outcomefalseCodeableConcept# complete | error | partial
patientfalseReference# The subject of the Products and Services
payeeTypefalseCodeableConcept# Party to be paid any benefits payable
paymentfalseData Type# Payment details, if paid
processNotetrueData Type# Processing notes
requestfalseReference# Id of resource triggering adjudication
requestOrganizationfalseReference# Responsible organization
requestProviderfalseReference# Responsible practitioner
reservedfalseCoding# Funds reserved status
statusfalsecode# active | cancelled | draft | entered-in-error
totalBenefitfalseMoney# Total benefit payable for the Claim
totalCostfalseMoney# Total Cost of service from the Claim
unallocDeductablefalseMoney# Unallocated deductible

ClaimResponse Example

{
  "status": "active",
  "requestOrganization": {
    "reference": "Organization/1"
  },
  "outcome": {
    "coding": [
      {
        "code": "complete",
        "system": "http://hl7.org/fhir/remittance-outcome"
      }
    ]
  },
  "patient": {
    "reference": "Patient/1"
  },
  "created": "2014-08-16",
  "resourceType": "ClaimResponse",
  "text": {
    "status": "generated",
    "div": "<div xmlns=\"http://www.w3.org/1999/xhtml\">A human-readable rendering of the ClaimResponse</div>"
  },
  "payment": {
    "date": "2014-08-31",
    "amount": {
      "code": "USD",
      "system": "urn:iso:std:iso:4217",
      "value": 100.47
    },
    "identifier": {
      "system": "http://www.BenefitsInc.com/fhir/paymentidentifier",
      "value": "201408-2-1569478"
    },
    "type": {
      "coding": [
        {
          "code": "complete",
          "system": "http://hl7.org/fhir/ex-paymenttype"
        }
      ]
    }
  },
  "insurer": {
    "identifier": {
      "system": "http://www.jurisdiction.org/insurers",
      "value": "555123"
    }
  },
  "request": {
    "reference": "http://www.BenefitsInc.com/fhir/oralhealthclaim/15476332402"
  },
  "totalBenefit": {
    "code": "USD",
    "system": "urn:iso:std:iso:4217",
    "value": 100.47
  },
  "item": [
    {
      "sequenceLinkId": 1,
      "adjudication": [
        {
          "category": {
            "coding": [
              {
                "code": "eligible"
              }
            ]
          },
          "amount": {
            "code": "USD",
            "system": "urn:iso:std:iso:4217",
            "value": 135.57
          }
        },
        {
          "category": {
            "coding": [
              {
                "code": "copay"
              }
            ]
          },
          "amount": {
            "code": "USD",
            "system": "urn:iso:std:iso:4217",
            "value": 10
          }
        },
        {
          "category": {
            "coding": [
              {
                "code": "eligpercent"
              }
            ]
          },
          "value": 80
        },
        {
          "category": {
            "coding": [
              {
                "code": "benefit"
              }
            ]
          },
          "amount": {
            "code": "USD",
            "system": "urn:iso:std:iso:4217",
            "value": 100.47
          }
        }
      ]
    }
  ],
  "totalCost": {
    "code": "USD",
    "system": "urn:iso:std:iso:4217",
    "value": 135.57
  },
  "payeeType": {
    "coding": [
      {
        "code": "provider",
        "system": "http://hl7.org/fhir/payeetype"
      }
    ]
  },
  "disposition": "Claim settled as per contract.",
  "requestProvider": {
    "reference": "Practitioner/1"
  },
  "identifier": [
    {
      "system": "http://www.BenefitsInc.com/fhir/remittance",
      "value": "R3500"
    }
  ],
  "id": "R3500"
}

ClaimResponse Structure


  
{
  "resourceType" : "ClaimResponse",
  // from Resource: id, meta, implicitRules, and language
  // from DomainResource: text, contained, extension, and modifierExtension
  "identifier" : [{ Identifier }], // Response  number
  "status" : "<code>", // active | cancelled | draft | entered-in-error
  "patient" : { Reference(Patient) }, // The subject of the Products and Services
  "created" : "<dateTime>", // Creation date
  "insurer" : { Reference(Organization) }, // Insurance issuing organization
  "requestProvider" : { Reference(Practitioner) }, // Responsible practitioner
  "requestOrganization" : { Reference(Organization) }, // Responsible organization
  "request" : { Reference(Claim) }, // Id of resource triggering adjudication
  "outcome" : { CodeableConcept }, // complete | error | partial
  "disposition" : "<string>", // Disposition Message
  "payeeType" : { CodeableConcept }, // 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
      "category" : { CodeableConcept }, // R!  Adjudication category such as co-pay, eligible, benefit, etc.
      "reason" : { CodeableConcept }, // Explanation of Adjudication outcome
      "amount" : { Money }, // Monetary amount
      "value" : <decimal> // Non-monetary value
    }],
    "detail" : [{ // Detail line items
      "sequenceLinkId" : "<positiveInt>", // R!  Service instance
      "noteNumber" : ["<positiveInt>"], // List of note numbers which apply
      "adjudication" : [{ Content as for ClaimResponse.item.adjudication }], // Detail level adjudication details
      "subDetail" : [{ // Subdetail line items
        "sequenceLinkId" : "<positiveInt>", // R!  Service instance
        "noteNumber" : ["<positiveInt>"], // List of note numbers which apply
        "adjudication" : [{ Content as for ClaimResponse.item.adjudication }] // Subdetail level adjudication details
      }]
    }]
  }],
  "addItem" : [{ // Insurer added line items
    "sequenceLinkId" : ["<positiveInt>"], // Service instances
    "revenue" : { CodeableConcept }, // Revenue or cost center code
    "category" : { CodeableConcept }, // Type of service or product
    "service" : { CodeableConcept }, // Group, Service or Product
    "modifier" : [{ CodeableConcept }], // Service/Product billing modifiers
    "fee" : { Money }, // Professional fee or Product charge
    "noteNumber" : ["<positiveInt>"], // List of note numbers which apply
    "adjudication" : [{ Content as for ClaimResponse.item.adjudication }], // Added items adjudication
    "detail" : [{ // Added items details
      "revenue" : { CodeableConcept }, // Revenue or cost center code
      "category" : { CodeableConcept }, // Type of service or product
      "service" : { CodeableConcept }, // Service or Product
      "modifier" : [{ CodeableConcept }], // Service/Product billing modifiers
      "fee" : { Money }, // Professional fee or Product charge
      "noteNumber" : ["<positiveInt>"], // List of note numbers which apply
      "adjudication" : [{ Content as for ClaimResponse.item.adjudication }] // Added items detail adjudication
    }]
  }],
  "error" : [{ // Processing errors
    "sequenceLinkId" : "<positiveInt>", // Item sequence number
    "detailSequenceLinkId" : "<positiveInt>", // Detail sequence number
    "subdetailSequenceLinkId" : "<positiveInt>", // Subdetail sequence number
    "code" : { CodeableConcept } // R!  Error code detailing processing issues
  }],
  "totalCost" : { Money }, // Total Cost of service from the Claim
  "unallocDeductable" : { Money }, // Unallocated deductible
  "totalBenefit" : { Money }, // Total benefit payable for the Claim
  "payment" : { // Payment details, if paid
    "type" : { CodeableConcept }, // Partial or Complete
    "adjustment" : { Money }, // Payment adjustment for non-Claim issues
    "adjustmentReason" : { CodeableConcept }, // Explanation for the non-claim adjustment
    "date" : "<date>", // Expected data of Payment
    "amount" : { Money }, // Payable amount after adjustment
    "identifier" : { Identifier } // Identifier of the payment instrument
  },
  "reserved" : { Coding }, // Funds reserved status
  "form" : { CodeableConcept }, // Printed Form Identifier
  "processNote" : [{ // Processing notes
    "number" : "<positiveInt>", // Sequence Number for this note
    "type" : { CodeableConcept }, // display | print | printoper
    "text" : "<string>", // Note explanatory text
    "language" : { CodeableConcept } // Language if different from the resource
  }],
  "communicationRequest" : [{ Reference(CommunicationRequest) }], // Request for additional information
  "insurance" : [{ // 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
    "preAuthRef" : ["<string>"], // Pre-Authorization/Determination Reference
    "claimResponse" : { Reference(ClaimResponse) } // Adjudication results
  }]
}


 

ClaimResponse Search Parameters

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

https://api.1up.health/fhir/stu3/ClaimResponse?query-param=queryvalue
Search ParameterField TypeResource Fields Searched
createddatecreated
dispositiontextdisposition
identifiertextidentifier
insurerreferenceinsurer
outcometextoutcome
patientreferencepatient
payment-datedatepayment.date
requestreferencerequest
request-providerreferencerequestProvider