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