ClaimResponse - FHIR Resource (stu3)
This ClaimResponse Resource uses the FHIR API standard for access and structure.
Validate an ClaimResponse FHIR Resource (stu3)
ClaimResponse Attributes
AttributeField is listTypeDescription
Description: Funds reserved status
FHIR Version: stu3
Attribute Type : Coding
Required: N/A
Countability: Singleton
Flags: N/A
Terminology bindings: N/A
Requirements: N/A
Comments: N/A
Example:
"reserved": Learn more about the (ClaimResponse) reserved FHIR attribute
Description: Responsible practitioner
FHIR Version: stu3
Attribute Type : Reference
Required: N/A
Countability: Singleton
Flags: N/A
Terminology bindings: N/A
Requirements: N/A
Comments: N/A
Example:
"requestProvider": {
"reference": "Practitioner/1"
}Learn more about the (ClaimResponse) requestProvider FHIR attribute
Description: Party to be paid any benefits payable
FHIR Version: stu3
Attribute Type : CodeableConcept
Required: N/A
Countability: Singleton
Flags: N/A
Terminology bindings: N/A
Requirements: N/A
Comments: N/A
Example:
"payeeType": {
"coding": [
{
"code": "provider",
"system": "http://hl7.org/fhir/payeetype"
}
]
}Learn more about the (ClaimResponse) payeeType FHIR attribute
Description: Processing notes
FHIR Version: stu3
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: Insurance or medical plan
FHIR Version: stu3
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: Total Cost of service from the Claim
FHIR Version: stu3
Attribute Type : Money
Required: N/A
Countability: Singleton
Flags: N/A
Terminology bindings: N/A
Requirements: N/A
Comments: N/A
Example:
"totalCost": {
"code": "USD",
"system": "urn:iso:std:iso:4217",
"value": 135.57
}Learn more about the (ClaimResponse) totalCost FHIR attribute
Description: Request for additional information
FHIR Version: stu3
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: active | cancelled | draft | entered-in-error
FHIR Version: stu3
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: The subject of the Products and Services
FHIR Version: stu3
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: Printed Form Identifier
FHIR Version: stu3
Attribute Type : CodeableConcept
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: Insurance issuing organization
FHIR Version: stu3
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: Insurer added line items
FHIR Version: stu3
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: Disposition Message
FHIR Version: stu3
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: Payment details, if paid
FHIR Version: stu3
Attribute Type : Data Type
Required: N/A
Countability: Singleton
Flags: N/A
Terminology bindings: N/A
Requirements: N/A
Comments: N/A
Example:
"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"
}
]
}
}Learn more about the (ClaimResponse) payment FHIR attribute
Description: Responsible organization
FHIR Version: stu3
Attribute Type : Reference
Required: N/A
Countability: Singleton
Flags: N/A
Terminology bindings: N/A
Requirements: N/A
Comments: N/A
Example:
"requestOrganization": {
"reference": "Organization/1"
}Learn more about the (ClaimResponse) requestOrganization FHIR attribute
Description: complete | error | partial
FHIR Version: stu3
Attribute Type : CodeableConcept
Required: N/A
Countability: Singleton
Flags: N/A
Terminology bindings: N/A
Requirements: N/A
Comments: N/A
Example:
"outcome": {
"coding": [
{
"code": "complete",
"system": "http://hl7.org/fhir/remittance-outcome"
}
]
}Learn more about the (ClaimResponse) outcome FHIR attribute
Description: Creation date
FHIR Version: stu3
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: Id of resource triggering adjudication
FHIR Version: stu3
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: Total benefit payable for the Claim
FHIR Version: stu3
Attribute Type : Money
Required: N/A
Countability: Singleton
Flags: N/A
Terminology bindings: N/A
Requirements: N/A
Comments: N/A
Example:
"totalBenefit": {
"code": "USD",
"system": "urn:iso:std:iso:4217",
"value": 100.47
}Learn more about the (ClaimResponse) totalBenefit FHIR attribute
Description: Unallocated deductible
FHIR Version: stu3
Attribute Type : Money
Required: N/A
Countability: Singleton
Flags: N/A
Terminology bindings: N/A
Requirements: N/A
Comments: N/A
Example:
"unallocDeductable": Learn more about the (ClaimResponse) unallocDeductable FHIR attribute
Description: Line items
FHIR Version: stu3
Attribute Type : Data Type
Required: N/A
Countability: Array
Flags: N/A
Terminology bindings: N/A
Requirements: N/A
Comments: N/A
Example:
"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
}
}
]
}
]Learn more about the (ClaimResponse) item FHIR attribute
Description: Processing errors
FHIR Version: stu3
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
Description: Response number
FHIR Version: stu3
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
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 |
