ClaimResponse - FHIR Resource (stu3)
This ClaimResponse Resource uses the FHIR API standard for access and structure.
Validate an ClaimResponse FHIR Resource (stu3)
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 them 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 |