ClaimResponse - FHIR Resource (r4)
This ClaimResponse Resource uses the FHIR API standard for access and structure.
Validate an ClaimResponse FHIR Resource (r4)
ClaimResponse Attributes
AttributeField is listTypeDescription
Description: Business Identifier for a claim response
FHIR Version: r4
Attribute Type : Identifier
Required: N/A
Countability: Array
Flags: N/A
Terminology bindings: N/A
Requirements: N/A
Comments: N/A
Example:
"identifier": [
{
"system": "http://www.BenefitsInc.com/fhir/remittance",
"value": "R3500"
}
]Learn more about the (ClaimResponse) identifier FHIR attribute
Description: active | cancelled | draft | entered-in-error
FHIR Version: r4
Attribute Type : code
Required: N/A
Countability: Singleton
Flags: N/A
Terminology bindings: N/A
Requirements: N/A
Comments: N/A
Example:
"status": "active"Learn more about the (ClaimResponse) status FHIR attribute
Description: More granular claim type
FHIR Version: r4
Attribute Type : CodeableConcept
Required: N/A
Countability: Singleton
Flags: N/A
Terminology bindings: N/A
Requirements: N/A
Comments: N/A
Example:
"type": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/claim-type",
"code": "oral"
}
]
}Learn more about the (ClaimResponse) type FHIR attribute
Description: More granular claim type
FHIR Version: r4
Attribute Type : CodeableConcept
Required: N/A
Countability: Singleton
Flags: N/A
Terminology bindings: N/A
Requirements: N/A
Comments: N/A
Example:
"subType": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/ex-claimsubtype",
"code": "emergency"
}
]
}Learn more about the (ClaimResponse) subType FHIR attribute
Description: claim | preauthorization | predetermination
FHIR Version: r4
Attribute Type : code
Required: N/A
Countability: Singleton
Flags: N/A
Terminology bindings: N/A
Requirements: N/A
Comments: N/A
Example:
"use": "claim"Learn more about the (ClaimResponse) use FHIR attribute
Description: The recipient of the products and services
FHIR Version: r4
Attribute Type : Reference
Required: N/A
Countability: Singleton
Flags: N/A
Terminology bindings: N/A
Requirements: N/A
Comments: N/A
Example:
"patient": {
"reference": "Patient/1"
}Learn more about the (ClaimResponse) patient FHIR attribute
Description: Response creation date
FHIR Version: r4
Attribute Type : dateTime
Required: N/A
Countability: Singleton
Flags: N/A
Terminology bindings: N/A
Requirements: N/A
Comments: N/A
Example:
"created": "2014-08-16"Learn more about the (ClaimResponse) created FHIR attribute
Description: Party responsible for reimbursement
FHIR Version: r4
Attribute Type : Reference
Required: N/A
Countability: Singleton
Flags: N/A
Terminology bindings: N/A
Requirements: N/A
Comments: N/A
Example:
"insurer": {
"identifier": {
"system": "http://www.jurisdiction.org/insurers",
"value": "555123"
}
}Learn more about the (ClaimResponse) insurer FHIR attribute
Description: Party responsible for the claim
FHIR Version: r4
Attribute Type : Reference
Required: N/A
Countability: Singleton
Flags: N/A
Terminology bindings: N/A
Requirements: N/A
Comments: N/A
Example:
"requestor": {
"reference": "Organization/1"
}Learn more about the (ClaimResponse) requestor FHIR attribute
Description: Id of resource triggering adjudication
FHIR Version: r4
Attribute Type : Reference
Required: N/A
Countability: Singleton
Flags: N/A
Terminology bindings: N/A
Requirements: N/A
Comments: N/A
Example:
"request": {
"reference": "http://www.BenefitsInc.com/fhir/oralhealthclaim/15476332402"
}Learn more about the (ClaimResponse) request FHIR attribute
Description: queued | complete | error | partial
FHIR Version: r4
Attribute Type : code
Required: N/A
Countability: Singleton
Flags: N/A
Terminology bindings: N/A
Requirements: N/A
Comments: N/A
Example:
"outcome": "complete"Learn more about the (ClaimResponse) outcome FHIR attribute
Description: Disposition Message
FHIR Version: r4
Attribute Type : string
Required: N/A
Countability: Singleton
Flags: N/A
Terminology bindings: N/A
Requirements: N/A
Comments: N/A
Example:
"disposition": "Claim settled as per contract."Learn more about the (ClaimResponse) disposition FHIR attribute
Description: Preauthorization reference
FHIR Version: r4
Attribute Type : string
Required: N/A
Countability: Singleton
Flags: N/A
Terminology bindings: N/A
Requirements: N/A
Comments: N/A
Example:
"preAuthRef": Learn more about the (ClaimResponse) preAuthRef FHIR attribute
Description: Preauthorization reference effective period
FHIR Version: r4
Attribute Type : Period
Required: N/A
Countability: Singleton
Flags: N/A
Terminology bindings: N/A
Requirements: N/A
Comments: N/A
Example:
"preAuthPeriod": Learn more about the (ClaimResponse) preAuthPeriod FHIR attribute
Description: Party to be paid any benefits payable
FHIR Version: r4
Attribute Type : CodeableConcept
Required: N/A
Countability: Singleton
Flags: N/A
Terminology bindings: N/A
Requirements: N/A
Comments: N/A
Example:
"payeeType": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/payeetype",
"code": "provider"
}
]
}Learn more about the (ClaimResponse) payeeType FHIR attribute
Description: Adjudication for claim line items
FHIR Version: r4
Attribute Type : Data Type
Required: N/A
Countability: Array
Flags: N/A
Terminology bindings: N/A
Requirements: N/A
Comments: N/A
Example:
"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"
}
}
]
}
]Learn more about the (ClaimResponse) item FHIR attribute
Description: Insurer added line items
FHIR Version: r4
Attribute Type : Data Type
Required: N/A
Countability: Array
Flags: N/A
Terminology bindings: N/A
Requirements: N/A
Comments: N/A
Example:
"addItem": Learn more about the (ClaimResponse) addItem FHIR attribute
Description: Adjudication details
FHIR Version: r4
Attribute Type : See ClaimResponse.item.adjudication
Required: N/A
Countability: Array
Flags: N/A
Terminology bindings: N/A
Requirements: N/A
Comments: N/A
Example:
"adjudication": Learn more about the (ClaimResponse) adjudication FHIR attribute
Description: Adjudication totals
FHIR Version: r4
Attribute Type : Data Type
Required: N/A
Countability: Array
Flags: N/A
Terminology bindings: N/A
Requirements: N/A
Comments: N/A
Example:
"total": [
{
"category": {
"coding": [
{
"code": "submitted"
}
]
},
"amount": {
"value": 135.57,
"currency": "USD"
}
},
{
"category": {
"coding": [
{
"code": "benefit"
}
]
},
"amount": {
"value": 90.47,
"currency": "USD"
}
}
]Learn more about the (ClaimResponse) total FHIR attribute
Description: Payment Details
FHIR Version: r4
Attribute Type : Data Type
Required: N/A
Countability: Singleton
Flags: N/A
Terminology bindings: N/A
Requirements: N/A
Comments: N/A
Example:
"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"
}
}Learn more about the (ClaimResponse) payment FHIR attribute
Description: Funds reserved status
FHIR Version: r4
Attribute Type : CodeableConcept
Required: N/A
Countability: Singleton
Flags: N/A
Terminology bindings: N/A
Requirements: N/A
Comments: N/A
Example:
"fundsReserve": Learn more about the (ClaimResponse) fundsReserve FHIR attribute
Description: Printed form identifier
FHIR Version: r4
Attribute Type : CodeableConcept
Required: N/A
Countability: Singleton
Flags: N/A
Terminology bindings: N/A
Requirements: N/A
Comments: N/A
Example:
"formCode": Learn more about the (ClaimResponse) formCode FHIR attribute
Description: Printed reference or actual form
FHIR Version: r4
Attribute Type : Attachment
Required: N/A
Countability: Singleton
Flags: N/A
Terminology bindings: N/A
Requirements: N/A
Comments: N/A
Example:
"form": Learn more about the (ClaimResponse) form FHIR attribute
Description: Note concerning adjudication
FHIR Version: r4
Attribute Type : Data Type
Required: N/A
Countability: Array
Flags: N/A
Terminology bindings: N/A
Requirements: N/A
Comments: N/A
Example:
"processNote": Learn more about the (ClaimResponse) processNote FHIR attribute
Description: Request for additional information
FHIR Version: r4
Attribute Type : Reference
Required: N/A
Countability: Array
Flags: N/A
Terminology bindings: N/A
Requirements: N/A
Comments: N/A
Example:
"communicationRequest": Learn more about the (ClaimResponse) communicationRequest FHIR attribute
Description: Patient insurance information
FHIR Version: r4
Attribute Type : Data Type
Required: N/A
Countability: Array
Flags: N/A
Terminology bindings: N/A
Requirements: N/A
Comments: N/A
Example:
"insurance": Learn more about the (ClaimResponse) insurance FHIR attribute
Description: Processing errors
FHIR Version: r4
Attribute Type : Data Type
Required: N/A
Countability: Array
Flags: N/A
Terminology bindings: N/A
Requirements: N/A
Comments: N/A
Example:
"error": Learn more about the (ClaimResponse) error FHIR attribute
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 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 |
requestor | reference | requestor |
status | text | status |
use | text | use |
