ClaimResponse - FHIR Resource (stu3)

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

Validate an ClaimResponse FHIR Resource (stu3)

Validate this ClaimResponse

Resource Attributes

Attribute	Field is list	Type	Description
addItem	true	Data Type	# Insurer added line items
communicationRequest	true	Reference	# Request for additional information
created	false	dateTime	# Creation date
disposition	false	string	# Disposition Message
error	true	Data Type	# Processing errors
form	false	CodeableConcept	# Printed Form Identifier
identifier	true	Identifier	# Response number
insurance	true	Data Type	# Insurance or medical plan
insurer	false	Reference	# Insurance issuing organization
item	true	Data Type	# Line items
outcome	false	CodeableConcept	# complete | error | partial
patient	false	Reference	# The subject of the Products and Services
payeeType	false	CodeableConcept	# Party to be paid any benefits payable
payment	false	Data Type	# Payment details, if paid
processNote	true	Data Type	# Processing notes
request	false	Reference	# Id of resource triggering adjudication
requestOrganization	false	Reference	# Responsible organization
requestProvider	false	Reference	# Responsible practitioner
reserved	false	Coding	# Funds reserved status
status	false	code	# active | cancelled | draft | entered-in-error
totalBenefit	false	Money	# Total benefit payable for the Claim
totalCost	false	Money	# Total Cost of service from the Claim
unallocDeductable	false	Money	# 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 Parameter	Field Type	Resource Fields Searched
created	date	created
disposition	text	disposition
identifier	text	identifier
insurer	reference	insurer
outcome	text	outcome
patient	reference	patient
payment-date	date	payment.date
request	reference	request
request-provider	reference	requestProvider