ClaimResponse - FHIR Resource (r4)


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

Validate an ClaimResponse FHIR Resource (r4)



Resource Attributes

AttributeField is listTypeDescription
addItemtrueData Type# Insurer added line items
adjudicationtrueSee ClaimResponse.item.adjudication# Adjudication details
communicationRequesttrueReference# Request for additional information
createdfalsedateTime# Response creation date
dispositionfalsestring# Disposition Message
errortrueData Type# Processing errors
formfalseAttachment# Printed reference or actual form
formCodefalseCodeableConcept# Printed form identifier
fundsReservefalseCodeableConcept# Funds reserved status
identifiertrueIdentifier# Business Identifier for a claim response
insurancetrueData Type# Patient insurance information
insurerfalseReference# Party responsible for reimbursement
itemtrueData Type# Adjudication for claim line items
outcomefalsecode# queued | complete | error | partial
patientfalseReference# The recipient of the products and services
payeeTypefalseCodeableConcept# Party to be paid any benefits payable
paymentfalseData Type# Payment Details
preAuthPeriodfalsePeriod# Preauthorization reference effective period
preAuthReffalsestring# Preauthorization reference
processNotetrueData Type# Note concerning adjudication
requestfalseReference# Id of resource triggering adjudication
requestorfalseReference# Party responsible for the claim
statusfalsecode# active | cancelled | draft | entered-in-error
subTypefalseCodeableConcept# More granular claim type
totaltrueData Type# Adjudication totals
typefalseCodeableConcept# More granular claim type
usefalsecode# claim | preauthorization | predetermination

ClaimResponse Example

{
  "resourceType": "ClaimResponse",
  "id": "R3500",
  "text": {
    "status": "generated",
    "div": "<div xmlns=\"http://www.w3.org/1999/xhtml\">A human-readable rendering of the ClaimResponse</div>"
  },
  "identifier": [
    {
      "system": "http://www.BenefitsInc.com/fhir/remittance",
      "value": "R3500"
    }
  ],
  "status": "active",
  "type": {
    "coding": [
      {
        "system": "http://terminology.hl7.org/CodeSystem/claim-type",
        "code": "oral"
      }
    ]
  },
  "subType": {
    "coding": [
      {
        "system": "http://terminology.hl7.org/CodeSystem/ex-claimsubtype",
        "code": "emergency"
      }
    ]
  },
  "use": "claim",
  "patient": {
    "reference": "Patient/1"
  },
  "created": "2014-08-16",
  "insurer": {
    "identifier": {
      "system": "http://www.jurisdiction.org/insurers",
      "value": "555123"
    }
  },
  "requestor": {
    "reference": "Organization/1"
  },
  "request": {
    "reference": "http://www.BenefitsInc.com/fhir/oralhealthclaim/15476332402"
  },
  "outcome": "complete",
  "disposition": "Claim settled as per contract.",
  "payeeType": {
    "coding": [
      {
        "system": "http://terminology.hl7.org/CodeSystem/payeetype",
        "code": "provider"
      }
    ]
  },
  "item": [
    {
      "itemSequence": 1,
      "adjudication": [
        {
          "category": {
            "coding": [
              {
                "code": "eligible"
              }
            ]
          },
          "amount": {
            "value": 135.57,
            "currency": "USD"
          }
        },
        {
          "category": {
            "coding": [
              {
                "code": "copay"
              }
            ]
          },
          "amount": {
            "value": 10,
            "currency": "USD"
          }
        },
        {
          "category": {
            "coding": [
              {
                "code": "eligpercent"
              }
            ]
          },
          "value": 80
        },
        {
          "category": {
            "coding": [
              {
                "code": "benefit"
              }
            ]
          },
          "reason": {
            "coding": [
              {
                "system": "http://terminology.hl7.org/CodeSystem/adjudication-reason",
                "code": "ar002",
                "display": "Plan Limit Reached"
              }
            ]
          },
          "amount": {
            "value": 90.47,
            "currency": "USD"
          }
        }
      ]
    }
  ],
  "total": [
    {
      "category": {
        "coding": [
          {
            "code": "submitted"
          }
        ]
      },
      "amount": {
        "value": 135.57,
        "currency": "USD"
      }
    },
    {
      "category": {
        "coding": [
          {
            "code": "benefit"
          }
        ]
      },
      "amount": {
        "value": 90.47,
        "currency": "USD"
      }
    }
  ],
  "payment": {
    "type": {
      "coding": [
        {
          "system": "http://terminology.hl7.org/CodeSystem/ex-paymenttype",
          "code": "complete"
        }
      ]
    },
    "date": "2014-08-31",
    "amount": {
      "value": 100.47,
      "currency": "USD"
    },
    "identifier": {
      "system": "http://www.BenefitsInc.com/fhir/paymentidentifier",
      "value": "201408-2-1569478"
    }
  }
}

ClaimResponse Structure

{
  "resourceType" : "ClaimResponse",
  // from Resource: id, meta, implicitRules, and language
  // from DomainResource: text, contained, extension, and modifierExtension
  "identifier" : [{ Identifier }], // Business Identifier for a claim response
  "status" : "<code>", // R!  active | cancelled | draft | entered-in-error
  "type" : { CodeableConcept }, // R!  More granular claim type
  "subType" : { CodeableConcept }, // More granular claim type
  "use" : "<code>", // R!  claim | preauthorization | predetermination
  "patient" : { Reference(Patient) }, // R!  The recipient of the products and services
  "created" : "<dateTime>", // R!  Response creation date
  "insurer" : { Reference(Organization) }, // R!  Party responsible for reimbursement
  "requestor" : { Reference(Practitioner|PractitionerRole|Organization) }, // Party responsible for the claim
  "request" : { Reference(Claim) }, // Id of resource triggering adjudication
  "outcome" : "<code>", // R!  queued | complete | error | partial
  "disposition" : "<string>", // Disposition Message
  "preAuthRef" : "<string>", // Preauthorization reference
  "preAuthPeriod" : { Period }, // Preauthorization reference effective period
  "payeeType" : { CodeableConcept }, // Party to be paid any benefits payable
  "item" : [{ // Adjudication for claim line items
    "itemSequence" : "<positiveInt>", // R!  Claim item instance identifier
    "noteNumber" : ["<positiveInt>"], // Applicable note numbers
    "adjudication" : [{ // R!  Adjudication details
      "category" : { CodeableConcept }, // R!  Type of adjudication information
      "reason" : { CodeableConcept }, // Explanation of adjudication outcome
      "amount" : { Money }, // Monetary amount
      "value" : <decimal> // Non-monetary value
    }],
    "detail" : [{ // Adjudication for claim details
      "detailSequence" : "<positiveInt>", // R!  Claim detail instance identifier
      "noteNumber" : ["<positiveInt>"], // Applicable note numbers
      "adjudication" : [{ Content as for ClaimResponse.item.adjudication }], // R!  Detail level adjudication details
      "subDetail" : [{ // Adjudication for claim sub-details
        "subDetailSequence" : "<positiveInt>", // R!  Claim sub-detail instance identifier
        "noteNumber" : ["<positiveInt>"], // Applicable note numbers
        "adjudication" : [{ Content as for ClaimResponse.item.adjudication }] // Subdetail level adjudication details
      }]
    }]
  }],
  "addItem" : [{ // Insurer added line items
    "itemSequence" : ["<positiveInt>"], // Item sequence number
    "detailSequence" : ["<positiveInt>"], // Detail sequence number
    "subdetailSequence" : ["<positiveInt>"], // Subdetail sequence number
    "provider" : [{ Reference(Practitioner|PractitionerRole|Organization) }], // Authorized providers
    "productOrService" : { CodeableConcept }, // R!  Billing, service, product, or drug code
    "modifier" : [{ CodeableConcept }], // Service/Product billing modifiers
    "programCode" : [{ CodeableConcept }], // Program the product or service is provided under
    // serviced[x]: Date or dates of service or product delivery. One of these 2:
    "servicedDate" : "<date>",
    "servicedPeriod" : { Period },
    // location[x]: Place of service or where product was supplied. One of these 3:
    "locationCodeableConcept" : { CodeableConcept },
    "locationAddress" : { Address },
    "locationReference" : { Reference(Location) },
    "quantity" : { Quantity(SimpleQuantity) }, // Count of products or services
    "unitPrice" : { Money }, // Fee, charge or cost per item
    "factor" : <decimal>, // Price scaling factor
    "net" : { Money }, // Total item cost
    "bodySite" : { CodeableConcept }, // Anatomical location
    "subSite" : [{ CodeableConcept }], // Anatomical sub-location
    "noteNumber" : ["<positiveInt>"], // Applicable note numbers
    "adjudication" : [{ Content as for ClaimResponse.item.adjudication }], // R!  Added items adjudication
    "detail" : [{ // Insurer added line details
      "productOrService" : { CodeableConcept }, // R!  Billing, service, product, or drug code
      "modifier" : [{ CodeableConcept }], // Service/Product billing modifiers
      "quantity" : { Quantity(SimpleQuantity) }, // Count of products or services
      "unitPrice" : { Money }, // Fee, charge or cost per item
      "factor" : <decimal>, // Price scaling factor
      "net" : { Money }, // Total item cost
      "noteNumber" : ["<positiveInt>"], // Applicable note numbers
      "adjudication" : [{ Content as for ClaimResponse.item.adjudication }], // R!  Added items detail adjudication
      "subDetail" : [{ // Insurer added line items
        "productOrService" : { CodeableConcept }, // R!  Billing, service, product, or drug code
        "modifier" : [{ CodeableConcept }], // Service/Product billing modifiers
        "quantity" : { Quantity(SimpleQuantity) }, // Count of products or services
        "unitPrice" : { Money }, // Fee, charge or cost per item
        "factor" : <decimal>, // Price scaling factor
        "net" : { Money }, // Total item cost
        "noteNumber" : ["<positiveInt>"], // Applicable note numbers
        "adjudication" : [{ Content as for ClaimResponse.item.adjudication }] // R!  Added items detail adjudication
      }]
    }]
  }],
  "adjudication" : [{ Content as for ClaimResponse.item.adjudication }], // Header-level adjudication
  "total" : [{ // Adjudication totals
    "category" : { CodeableConcept }, // R!  Type of adjudication information
    "amount" : { Money } // R!  Financial total for the category
  }],
  "payment" : { // Payment Details
    "type" : { CodeableConcept }, // R!  Partial or complete payment
    "adjustment" : { Money }, // Payment adjustment for non-claim issues
    "adjustmentReason" : { CodeableConcept }, // Explanation for the adjustment
    "date" : "<date>", // Expected date of payment
    "amount" : { Money }, // R!  Payable amount after adjustment
    "identifier" : { Identifier } // Business identifier for the payment
  },
  "fundsReserve" : { CodeableConcept }, // Funds reserved status
  "formCode" : { CodeableConcept }, // Printed form identifier
  "form" : { Attachment }, // Printed reference or actual form
  "processNote" : [{ // Note concerning adjudication
    "number" : "<positiveInt>", // Note instance identifier
    "type" : "<code>", // display | print | printoper
    "text" : "<string>", // R!  Note explanatory text
    "language" : { CodeableConcept } // Language of the text
  }],
  "communicationRequest" : [{ Reference(CommunicationRequest) }], // Request for additional information
  "insurance" : [{ // Patient insurance information
    "sequence" : "<positiveInt>", // R!  Insurance instance identifier
    "focal" : <boolean>, // R!  Coverage to be used for adjudication
    "coverage" : { Reference(Coverage) }, // R!  Insurance information
    "businessArrangement" : "<string>", // Additional provider contract number
    "claimResponse" : { Reference(ClaimResponse) } // Adjudication results
  }],
  "error" : [{ // Processing errors
    "itemSequence" : "<positiveInt>", // Item sequence number
    "detailSequence" : "<positiveInt>", // Detail sequence number
    "subDetailSequence" : "<positiveInt>", // Subdetail sequence number
    "code" : { CodeableConcept } // R!  Error code detailing processing issues
  }]
}

ClaimResponse Search Parameters

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

https://api.1up.health/fhir/r4/ClaimResponse?query-param=queryvalue
Search ParameterField TypeResource Fields Searched
createddatecreated
dispositiontextdisposition
identifiertextidentifier
insurerreferenceinsurer
outcometextoutcome
patientreferencepatient
payment-datedatepayment.date
requestreferencerequest
requestorreferencerequestor
statustextstatus
usetextuse