--- type: "resource" title: "ClaimResponse" resource: "ClaimResponse" --- # ClaimResponse ## Introduction ## Scope and Usage The ClaimResponse resource provides application level adjudication results, or an application level error, which are the result of processing a submitted Claim resource where that Claim may be the functional corollary of a Claim, Predetermination or a Preauthorization.This resource is the only appropriate response to a Claim which a processing system recognizes as a Claim resource. This is the adjudicated response to a Claim, Predetermination or Preauthorization. The strength of the payment aspect of the response is matching to the strength of the original request. For a Claim the adjudication indicates payment which is intended to be made. For Preauthorization no payment will actually be made however funds may be reserved to settle a claim submitted later. For Predetermination no payment will actually be made and no assurance is given that the adjudication of a claim submitted later will match the adjudication provided, for example funds may have been exhausted in the interim. Only an actual claim may be expected to result in actual payment. The ClaimResponse resource may also be returned with the response for the submission of: Re-adjudication and Reversals. The ClaimResponse resource is an "event" resource from a FHIR workflow perspective - see [Workflow Event.](workflow#event) ### Additional Information Additional information regarding electronic claims content and usage may be found at: - [Financial Resource Status Lifecycle](financial-module#resource-status): how .status is used in the financial resources. - [Secondary Use of Resources](financial-module#secondary-use): how resources such as Claim, ClaimResponse and ExplanationOfBenefit may be used for reporting and data exchange for analytics, not just for eClaims exchange between providers and payers. - [Subrogation](financial-module#subrogation): how eClaims may handle patient insurance coverages when another insurer rather than the provider will settle the claim and potentially recover costs against specified coverages. - [Coordination of Benefit](financial-module#cob): how eClaims may handle multiple patient insurance coverages. - [RealTime Exchange and Obtaining Deferred Responsess](financial-module#real-time): ClaimResponses may be obtained using Polling or FHIR REST (SEARCH). - [Attachments and Supporting Information](financial-module#attachments): how eClaims may handle the provision of supporting information, whether provided by content or reference, within the eClaim resource when submitted to the payer or later in a resource which refers to the subject eClaim resource. This also includes how payers may request additional supporting information from providers. - [3-Tier Line Item Hierarchy](financial-module#3-tier): 3-tier hierarchy of Goods, products, and Services, to support simple to complex billing. - [Tax](financial-module#tax): Tax handling of Goods, products, and Services. ## Boundaries and Relationships The ClaimResponse resource is used to provide the results of the adjudication and/or authorization of a set of healthcare-related products and services for a patient against the patient's insurance coverages, or to respond with what the adjudication would be for a supplied set of products or services should they be actually supplied to the patient. The [ExplanationOfBenefit](explanationofbenefit) resource is for reporting out to patients or transferring data to patient centered applications, such as patient health Record (PHR) application, the [ExplanationOfBenefit](explanationofbenefit) should be used instead of the [Claim](claim) and [ClaimResponse](claimresponse) resources as those resources may contain provider and payer specific information which is not appropriate for sharing with the patient. When using the resources for reporting and transferring claims data, which may have originated in some standard other than FHIR, the Claim resource is useful if only the request side of the information exchange is of interest. If, however, both the request and the adjudication information is to be reported then the [ExplanationOfBenefit](explanationofbenefit) should be used instead. When responding whether the patient's coverage is inforce, whether it is valid at this or a specified date, or returning the benefit details or preauthorization requirements associated with a coverage [CoverageEligibilityResponse](coverageeligibilityresponse) should be used instead and be the response to a [CoverageEligibilityRequest](coverageeligibilityrequest). **The eClaim domain includes a number of related resources** | ClaimResponse | A payer's adjudication and/or authorization response to the suite of services provided in a Claim. Typically the ClaimResponse references the Claim but does not duplicate the clinical or financial information provided in the claim. | | --- | --- | | [ExplanationOfBenefit](explanationofbenefit) | This resource combines the information from the Claim and the ClaimResponse, stripping out any provider or payer proprietary information, into a unified information model suitable for use for: patient reporting; transferring information to a Patient Health Record system; and, supporting complete claim and adjudication information exchange with regulatory and analytics organizations and other parts of the provider's organization. | | [Claim](claim) | A suite of goods and services and insurances coverages under which adjudication or authorization is requested. | | [CoverageEligibilityResponse](coverageeligibilityresponse) | The response to a request to a payer, a [CoverageEligibilityRequest](coverageeligibilityrequest), to: ascertain whether a coverage is in-force at the current or at a specified time; list the table of benefits; determine whether coverage is provided for specified categories or specific services; and whether preauthorization is required, and if so what supporting information would be required. | ## Background and Context Provides additional detail on exactly how the resource is to be used ## Notes ## Additional Information The information presented in different backbone elements, such as **.supportingInfo** or **.adjudication**, has a different context based on the **.category** code presented in each, for example, adjudication occurrence may represent an amount paid by the patient while another may represent the amount paid to the provider. Additionally, there are several places in the resource which point to other sections of the resource via the use of a **.sequence** number in the referred-to element and an **._element_Sequence** in the referring element. Sequence numbers appear in such element as **.careTeam** referred to by **.careTeamSequence**, **.diagnosis** referred to by **.diagnosisSequence**, **.procedure** referred to by **.procedureSequence**, **.supportingInfo** referred to by **.informationSequence** and **.item** referred to by **.itemSequence**. The **.noteNumber** element, which appears at the **.item**, **.detail** and **.subDetail** levels in the **.item** and **.addItem** structures, contains a list of numbers which match the value of the **.number** element in the **.processNote** structure. The process notes are indivdual chunks of text describing a situation associated with insurer explanation of adjudication results. Rather than repeating the same text in the adjudication of line item or detail, the insurer can provide the text once in the **.processNote** structure then include the associated number value in the list of **.noteNumber**s for each of the appropriate line items or details. ## StructureDefinition ### Elements (Simplified) - **[ClaimResponse](/claimresponse-definitions#ClaimResponse)** [0..*]: - Response to a claim predetermination or preauthorization - **[ClaimResponse.identifier](/claimresponse-definitions#ClaimResponse.identifier)** [0..*]: [Identifier](/Identifier) Business Identifier for a claim response - **[ClaimResponse.traceNumber](/claimresponse-definitions#ClaimResponse.traceNumber)** [0..*]: [Identifier](/Identifier) Number for tracking - **[ClaimResponse.status](/claimresponse-definitions#ClaimResponse.status)** [1..1]: [code](/code) required:[fm-status](/valueset-fm-status) active | cancelled | draft | entered-in-error - **[ClaimResponse.statusReason](/claimresponse-definitions#ClaimResponse.statusReason)** [0..1]: [string](/string) Reason for status change - **[ClaimResponse.type](/claimresponse-definitions#ClaimResponse.type)** [1..1]: [CodeableConcept](/CodeableConcept) extensible:[claim-type](/valueset-claim-type) More granular claim type - **[ClaimResponse.subType](/claimresponse-definitions#ClaimResponse.subType)** [0..1]: [CodeableConcept](/CodeableConcept) example:[claim-subtype](/valueset-claim-subtype) More granular claim type - **[ClaimResponse.use](/claimresponse-definitions#ClaimResponse.use)** [1..1]: [code](/code) required:[claim-use](/valueset-claim-use) claim | preauthorization | predetermination - **[ClaimResponse.subject](/claimresponse-definitions#ClaimResponse.subject)** [1..1]: [Reference(Patient](/Reference(Patient), [Group)](/Group)) The recipient(s) of the products and services - **[ClaimResponse.created](/claimresponse-definitions#ClaimResponse.created)** [1..1]: [dateTime](/dateTime) Response creation date - **[ClaimResponse.insurer](/claimresponse-definitions#ClaimResponse.insurer)** [0..1]: Reference([Organization](/Organization)) Party responsible for reimbursement - **[ClaimResponse.requestor](/claimresponse-definitions#ClaimResponse.requestor)** [0..1]: [Reference(Practitioner](/Reference(Practitioner), [PractitionerRole](/PractitionerRole), [Organization)](/Organization)) Party responsible for the claim - **[ClaimResponse.request](/claimresponse-definitions#ClaimResponse.request)** [0..1]: Reference([Claim](/Claim)) Id of resource triggering adjudication - **[ClaimResponse.outcome](/claimresponse-definitions#ClaimResponse.outcome)** [1..1]: [code](/code) required:[claim-outcome](/valueset-claim-outcome) queued | complete | error | partial - **[ClaimResponse.decision](/claimresponse-definitions#ClaimResponse.decision)** [0..1]: [CodeableConcept](/CodeableConcept) preferred:[claim-decision](/valueset-claim-decision) Result of the adjudication - **[ClaimResponse.disposition](/claimresponse-definitions#ClaimResponse.disposition)** [0..1]: [string](/string) Disposition Message - **[ClaimResponse.preAuthRef](/claimresponse-definitions#ClaimResponse.preAuthRef)** [0..1]: [string](/string) Preauthorization reference - **[ClaimResponse.preAuthPeriod](/claimresponse-definitions#ClaimResponse.preAuthPeriod)** [0..1]: [Period](/Period) Preauthorization reference effective period - **[ClaimResponse.event](/claimresponse-definitions#ClaimResponse.event)** [0..*]: [BackboneElement](/BackboneElement) Event information - **[ClaimResponse.event.type](/claimresponse-definitions#ClaimResponse.event.type)** [1..1]: [CodeableConcept](/CodeableConcept) example:[datestype](/valueset-datestype) Specific event - **[ClaimResponse.event.when[x]](/claimresponse-definitions#ClaimResponse.event.when%5Bx%5D)** [1..1]: [dateTime](/dateTime), [Period](/Period) Occurance date or period - **[ClaimResponse.payeeType](/claimresponse-definitions#ClaimResponse.payeeType)** [0..1]: [CodeableConcept](/CodeableConcept) example:[payeetype](/valueset-payeetype) Party to be paid any benefits payable - **[ClaimResponse.encounter](/claimresponse-definitions#ClaimResponse.encounter)** [0..*]: Reference([Encounter](/Encounter)) Encounters associated with the listed treatments - **[ClaimResponse.diagnosisRelatedGroup](/claimresponse-definitions#ClaimResponse.diagnosisRelatedGroup)** [0..1]: [CodeableConcept](/CodeableConcept) example:[ex-diagnosisrelatedgroup](/valueset-ex-diagnosisrelatedgroup) Package billing code - **[ClaimResponse.supportingInfo](/claimresponse-definitions#ClaimResponse.supportingInfo)** [0..*]: [BackboneElement](/BackboneElement) Supporting information - **[ClaimResponse.supportingInfo.sequence](/claimresponse-definitions#ClaimResponse.supportingInfo.sequence)** [1..1]: [positiveInt](/positiveInt) Information instance identifier - **[ClaimResponse.supportingInfo.category](/claimresponse-definitions#ClaimResponse.supportingInfo.category)** [1..1]: [CodeableConcept](/CodeableConcept) preferred:[claim-informationcategory](/valueset-claim-informationcategory) Classification of the supplied information - **[ClaimResponse.supportingInfo.code](/claimresponse-definitions#ClaimResponse.supportingInfo.code)** [0..1]: [CodeableConcept](/CodeableConcept) example:[claim-exception](/valueset-claim-exception) Type of information - **[ClaimResponse.supportingInfo.timing[x]](/claimresponse-definitions#ClaimResponse.supportingInfo.timing%5Bx%5D)** [0..1]: [dateTime](/dateTime), [Period](/Period), [Timing](/Timing) When it occurred - **[ClaimResponse.supportingInfo.value[x]](/claimresponse-definitions#ClaimResponse.supportingInfo.value%5Bx%5D)** [0..1]: [*](/*) Data to be provided - **[ClaimResponse.supportingInfo.reason](/claimresponse-definitions#ClaimResponse.supportingInfo.reason)** [0..1]: [CodeableConcept](/CodeableConcept) example:[missing-tooth-reason](/valueset-missing-tooth-reason) Explanation for the information - **[ClaimResponse.item](/claimresponse-definitions#ClaimResponse.item)** [0..*]: [BackboneElement](/BackboneElement) Adjudication for claim line items - **[ClaimResponse.item.itemSequence](/claimresponse-definitions#ClaimResponse.item.itemSequence)** [1..1]: [positiveInt](/positiveInt) Claim item instance identifier - **[ClaimResponse.item.traceNumber](/claimresponse-definitions#ClaimResponse.item.traceNumber)** [0..*]: [Identifier](/Identifier) Number for tracking - **[ClaimResponse.item.informationSequence](/claimresponse-definitions#ClaimResponse.item.informationSequence)** [0..*]: [positiveInt](/positiveInt) Applicable exception and supporting information - **[ClaimResponse.item.noteNumber](/claimresponse-definitions#ClaimResponse.item.noteNumber)** [0..*]: [positiveInt](/positiveInt) Applicable note numbers - **[ClaimResponse.item.reviewOutcome](/claimresponse-definitions#ClaimResponse.item.reviewOutcome)** [0..1]: [BackboneElement](/BackboneElement) Adjudication results - **[ClaimResponse.item.reviewOutcome.decision](/claimresponse-definitions#ClaimResponse.item.reviewOutcome.decision)** [0..1]: [CodeableConcept](/CodeableConcept) preferred:[claim-decision](/valueset-claim-decision) Result of the adjudication - **[ClaimResponse.item.reviewOutcome.reason](/claimresponse-definitions#ClaimResponse.item.reviewOutcome.reason)** [0..*]: [CodeableConcept](/CodeableConcept) example:[claim-decision-reason](/valueset-claim-decision-reason) Reason for result of the adjudication - **[ClaimResponse.item.reviewOutcome.preAuthRef](/claimresponse-definitions#ClaimResponse.item.reviewOutcome.preAuthRef)** [0..1]: [string](/string) Preauthorization reference - **[ClaimResponse.item.reviewOutcome.preAuthPeriod](/claimresponse-definitions#ClaimResponse.item.reviewOutcome.preAuthPeriod)** [0..1]: [Period](/Period) Preauthorization reference effective period - **[ClaimResponse.item.adjudication](/claimresponse-definitions#ClaimResponse.item.adjudication)** [0..*]: [BackboneElement](/BackboneElement) Adjudication details - **[ClaimResponse.item.adjudication.category](/claimresponse-definitions#ClaimResponse.item.adjudication.category)** [1..1]: [CodeableConcept](/CodeableConcept) preferred:[adjudication](/valueset-adjudication) Type of adjudication information - **[ClaimResponse.item.adjudication.reason](/claimresponse-definitions#ClaimResponse.item.adjudication.reason)** [0..1]: [CodeableConcept](/CodeableConcept) example:[adjudication-reason](/valueset-adjudication-reason) Explanation of adjudication outcome - **[ClaimResponse.item.adjudication.amount](/claimresponse-definitions#ClaimResponse.item.adjudication.amount)** [0..1]: [Money](/Money) Monetary amount - **[ClaimResponse.item.adjudication.quantity](/claimresponse-definitions#ClaimResponse.item.adjudication.quantity)** [0..1]: [Quantity](/Quantity) Non-monetary value - **[ClaimResponse.item.adjudication.decisionDate](/claimresponse-definitions#ClaimResponse.item.adjudication.decisionDate)** [0..1]: [dateTime](/dateTime) When was adjudication performed - **[ClaimResponse.item.detail](/claimresponse-definitions#ClaimResponse.item.detail)** [0..*]: [BackboneElement](/BackboneElement) Adjudication for claim details - **[ClaimResponse.item.detail.detailSequence](/claimresponse-definitions#ClaimResponse.item.detail.detailSequence)** [1..1]: [positiveInt](/positiveInt) Claim detail instance identifier - **[ClaimResponse.item.detail.traceNumber](/claimresponse-definitions#ClaimResponse.item.detail.traceNumber)** [0..*]: [Identifier](/Identifier) Number for tracking - **[ClaimResponse.item.detail.noteNumber](/claimresponse-definitions#ClaimResponse.item.detail.noteNumber)** [0..*]: [positiveInt](/positiveInt) Applicable note numbers - **[ClaimResponse.item.detail.reviewOutcome](/claimresponse-definitions#ClaimResponse.item.detail.reviewOutcome)** [0..1]: - Detail level adjudication results - **[ClaimResponse.item.detail.adjudication](/claimresponse-definitions#ClaimResponse.item.detail.adjudication)** [0..*]: - Detail level adjudication details - **[ClaimResponse.item.detail.subDetail](/claimresponse-definitions#ClaimResponse.item.detail.subDetail)** [0..*]: [BackboneElement](/BackboneElement) Adjudication for claim sub-details - **[ClaimResponse.item.detail.subDetail.subDetailSequence](/claimresponse-definitions#ClaimResponse.item.detail.subDetail.subDetailSequence)** [1..1]: [positiveInt](/positiveInt) Claim sub-detail instance identifier - **[ClaimResponse.item.detail.subDetail.traceNumber](/claimresponse-definitions#ClaimResponse.item.detail.subDetail.traceNumber)** [0..*]: [Identifier](/Identifier) Number for tracking - **[ClaimResponse.item.detail.subDetail.noteNumber](/claimresponse-definitions#ClaimResponse.item.detail.subDetail.noteNumber)** [0..*]: [positiveInt](/positiveInt) Applicable note numbers - **[ClaimResponse.item.detail.subDetail.reviewOutcome](/claimresponse-definitions#ClaimResponse.item.detail.subDetail.reviewOutcome)** [0..1]: - Subdetail level adjudication results - **[ClaimResponse.item.detail.subDetail.adjudication](/claimresponse-definitions#ClaimResponse.item.detail.subDetail.adjudication)** [0..*]: - Subdetail level adjudication details - **[ClaimResponse.addItem](/claimresponse-definitions#ClaimResponse.addItem)** [0..*]: [BackboneElement](/BackboneElement) Insurer added line items - **[ClaimResponse.addItem.itemSequence](/claimresponse-definitions#ClaimResponse.addItem.itemSequence)** [0..*]: [positiveInt](/positiveInt) Item sequence number - **[ClaimResponse.addItem.detailSequence](/claimresponse-definitions#ClaimResponse.addItem.detailSequence)** [0..*]: [positiveInt](/positiveInt) Detail sequence number - **[ClaimResponse.addItem.subdetailSequence](/claimresponse-definitions#ClaimResponse.addItem.subdetailSequence)** [0..*]: [positiveInt](/positiveInt) Subdetail sequence number - **[ClaimResponse.addItem.traceNumber](/claimresponse-definitions#ClaimResponse.addItem.traceNumber)** [0..*]: [Identifier](/Identifier) Number for tracking - **[ClaimResponse.addItem.subject](/claimresponse-definitions#ClaimResponse.addItem.subject)** [0..1]: [Reference(Patient](/Reference(Patient), [Group)](/Group)) The recipient of the products and services - **[ClaimResponse.addItem.informationSequence](/claimresponse-definitions#ClaimResponse.addItem.informationSequence)** [0..*]: [positiveInt](/positiveInt) Applicable exception and supporting information - **[ClaimResponse.addItem.provider](/claimresponse-definitions#ClaimResponse.addItem.provider)** [0..*]: [Reference(Practitioner](/Reference(Practitioner), [PractitionerRole](/PractitionerRole), [Organization)](/Organization)) Authorized providers - **[ClaimResponse.addItem.revenue](/claimresponse-definitions#ClaimResponse.addItem.revenue)** [0..1]: [CodeableConcept](/CodeableConcept) example:[ex-revenue-center](/valueset-ex-revenue-center) Revenue or cost center code - **[ClaimResponse.addItem.category](/claimresponse-definitions#ClaimResponse.addItem.category)** [0..1]: [CodeableConcept](/CodeableConcept) example:[ex-benefitcategory](/valueset-ex-benefitcategory) Benefit classification - **[ClaimResponse.addItem.productOrService](/claimresponse-definitions#ClaimResponse.addItem.productOrService)** [0..1]: [CodeableConcept](/CodeableConcept) example:[service-uscls](/valueset-service-uscls) Billing, service, product, or drug code - **[ClaimResponse.addItem.productOrServiceEnd](/claimresponse-definitions#ClaimResponse.addItem.productOrServiceEnd)** [0..1]: [CodeableConcept](/CodeableConcept) example:[service-uscls](/valueset-service-uscls) End of a range of codes - **[ClaimResponse.addItem.request](/claimresponse-definitions#ClaimResponse.addItem.request)** [0..*]: [Reference(DeviceRequest](/Reference(DeviceRequest), [MedicationRequest](/MedicationRequest), [NutritionOrder](/NutritionOrder), [ServiceRequest](/ServiceRequest), [VisionPrescription)](/VisionPrescription)) Request or Referral for Service - **[ClaimResponse.addItem.modifier](/claimresponse-definitions#ClaimResponse.addItem.modifier)** [0..*]: [CodeableConcept](/CodeableConcept) example:[claim-modifiers](/valueset-claim-modifiers) Service/Product billing modifiers - **[ClaimResponse.addItem.programCode](/claimresponse-definitions#ClaimResponse.addItem.programCode)** [0..*]: [CodeableConcept](/CodeableConcept) example:[ex-program-code](/valueset-ex-program-code) Program the product or service is provided under - **[ClaimResponse.addItem.serviced[x]](/claimresponse-definitions#ClaimResponse.addItem.serviced%5Bx%5D)** [0..1]: [date](/date), [Period](/Period) Date or dates of service or product delivery - **[ClaimResponse.addItem.location[x]](/claimresponse-definitions#ClaimResponse.addItem.location%5Bx%5D)** [0..1]: [CodeableConcept](/CodeableConcept), [Address](/Address), Reference([Location](/Location)) example:[service-place](/valueset-service-place) Place of service or where product was supplied - **[ClaimResponse.addItem.quantity](/claimresponse-definitions#ClaimResponse.addItem.quantity)** [0..1]: [Quantity](/Quantity)([SimpleQuantity](/SimpleQuantity)) Count of products or services - **[ClaimResponse.addItem.unitPrice](/claimresponse-definitions#ClaimResponse.addItem.unitPrice)** [0..1]: [Money](/Money) Fee, charge or cost per item - **[ClaimResponse.addItem.factor](/claimresponse-definitions#ClaimResponse.addItem.factor)** [0..1]: [decimal](/decimal) Price scaling factor - **[ClaimResponse.addItem.tax](/claimresponse-definitions#ClaimResponse.addItem.tax)** [0..1]: [Money](/Money) Total tax - **[ClaimResponse.addItem.net](/claimresponse-definitions#ClaimResponse.addItem.net)** [0..1]: [Money](/Money) Total item cost - **[ClaimResponse.addItem.bodySite](/claimresponse-definitions#ClaimResponse.addItem.bodySite)** [0..*]: [BackboneElement](/BackboneElement) Anatomical location - **[ClaimResponse.addItem.bodySite.site](/claimresponse-definitions#ClaimResponse.addItem.bodySite.site)** [1..*]: [CodeableReference](/CodeableReference) example:[tooth](/valueset-tooth) Location - **[ClaimResponse.addItem.bodySite.subSite](/claimresponse-definitions#ClaimResponse.addItem.bodySite.subSite)** [0..*]: [CodeableConcept](/CodeableConcept) example:[surface](/valueset-surface) Sub-location - **[ClaimResponse.addItem.noteNumber](/claimresponse-definitions#ClaimResponse.addItem.noteNumber)** [0..*]: [positiveInt](/positiveInt) Applicable note numbers - **[ClaimResponse.addItem.reviewOutcome](/claimresponse-definitions#ClaimResponse.addItem.reviewOutcome)** [0..1]: - Added items adjudication results - **[ClaimResponse.addItem.adjudication](/claimresponse-definitions#ClaimResponse.addItem.adjudication)** [0..*]: - Added items adjudication - **[ClaimResponse.addItem.detail](/claimresponse-definitions#ClaimResponse.addItem.detail)** [0..*]: [BackboneElement](/BackboneElement) Insurer added line details - **[ClaimResponse.addItem.detail.traceNumber](/claimresponse-definitions#ClaimResponse.addItem.detail.traceNumber)** [0..*]: [Identifier](/Identifier) Number for tracking - **[ClaimResponse.addItem.detail.revenue](/claimresponse-definitions#ClaimResponse.addItem.detail.revenue)** [0..1]: [CodeableConcept](/CodeableConcept) example:[ex-revenue-center](/valueset-ex-revenue-center) Revenue or cost center code - **[ClaimResponse.addItem.detail.productOrService](/claimresponse-definitions#ClaimResponse.addItem.detail.productOrService)** [0..1]: [CodeableConcept](/CodeableConcept) example:[service-uscls](/valueset-service-uscls) Billing, service, product, or drug code - **[ClaimResponse.addItem.detail.productOrServiceEnd](/claimresponse-definitions#ClaimResponse.addItem.detail.productOrServiceEnd)** [0..1]: [CodeableConcept](/CodeableConcept) example:[service-uscls](/valueset-service-uscls) End of a range of codes - **[ClaimResponse.addItem.detail.modifier](/claimresponse-definitions#ClaimResponse.addItem.detail.modifier)** [0..*]: [CodeableConcept](/CodeableConcept) example:[claim-modifiers](/valueset-claim-modifiers) Service/Product billing modifiers - **[ClaimResponse.addItem.detail.quantity](/claimresponse-definitions#ClaimResponse.addItem.detail.quantity)** [0..1]: [Quantity](/Quantity)([SimpleQuantity](/SimpleQuantity)) Count of products or services - **[ClaimResponse.addItem.detail.unitPrice](/claimresponse-definitions#ClaimResponse.addItem.detail.unitPrice)** [0..1]: [Money](/Money) Fee, charge or cost per item - **[ClaimResponse.addItem.detail.factor](/claimresponse-definitions#ClaimResponse.addItem.detail.factor)** [0..1]: [decimal](/decimal) Price scaling factor - **[ClaimResponse.addItem.detail.tax](/claimresponse-definitions#ClaimResponse.addItem.detail.tax)** [0..1]: [Money](/Money) Total tax - **[ClaimResponse.addItem.detail.net](/claimresponse-definitions#ClaimResponse.addItem.detail.net)** [0..1]: [Money](/Money) Total item cost - **[ClaimResponse.addItem.detail.noteNumber](/claimresponse-definitions#ClaimResponse.addItem.detail.noteNumber)** [0..*]: [positiveInt](/positiveInt) Applicable note numbers - **[ClaimResponse.addItem.detail.reviewOutcome](/claimresponse-definitions#ClaimResponse.addItem.detail.reviewOutcome)** [0..1]: - Added items detail level adjudication results - **[ClaimResponse.addItem.detail.adjudication](/claimresponse-definitions#ClaimResponse.addItem.detail.adjudication)** [0..*]: - Added items detail adjudication - **[ClaimResponse.addItem.detail.subDetail](/claimresponse-definitions#ClaimResponse.addItem.detail.subDetail)** [0..*]: [BackboneElement](/BackboneElement) Insurer added line items - **[ClaimResponse.addItem.detail.subDetail.traceNumber](/claimresponse-definitions#ClaimResponse.addItem.detail.subDetail.traceNumber)** [0..*]: [Identifier](/Identifier) Number for tracking - **[ClaimResponse.addItem.detail.subDetail.revenue](/claimresponse-definitions#ClaimResponse.addItem.detail.subDetail.revenue)** [0..1]: [CodeableConcept](/CodeableConcept) example:[ex-revenue-center](/valueset-ex-revenue-center) Revenue or cost center code - **[ClaimResponse.addItem.detail.subDetail.productOrService](/claimresponse-definitions#ClaimResponse.addItem.detail.subDetail.productOrService)** [0..1]: [CodeableConcept](/CodeableConcept) example:[service-uscls](/valueset-service-uscls) Billing, service, product, or drug code - **[ClaimResponse.addItem.detail.subDetail.productOrServiceEnd](/claimresponse-definitions#ClaimResponse.addItem.detail.subDetail.productOrServiceEnd)** [0..1]: [CodeableConcept](/CodeableConcept) example:[service-uscls](/valueset-service-uscls) End of a range of codes - **[ClaimResponse.addItem.detail.subDetail.modifier](/claimresponse-definitions#ClaimResponse.addItem.detail.subDetail.modifier)** [0..*]: [CodeableConcept](/CodeableConcept) example:[claim-modifiers](/valueset-claim-modifiers) Service/Product billing modifiers - **[ClaimResponse.addItem.detail.subDetail.quantity](/claimresponse-definitions#ClaimResponse.addItem.detail.subDetail.quantity)** [0..1]: [Quantity](/Quantity)([SimpleQuantity](/SimpleQuantity)) Count of products or services - **[ClaimResponse.addItem.detail.subDetail.unitPrice](/claimresponse-definitions#ClaimResponse.addItem.detail.subDetail.unitPrice)** [0..1]: [Money](/Money) Fee, charge or cost per item - **[ClaimResponse.addItem.detail.subDetail.factor](/claimresponse-definitions#ClaimResponse.addItem.detail.subDetail.factor)** [0..1]: [decimal](/decimal) Price scaling factor - **[ClaimResponse.addItem.detail.subDetail.tax](/claimresponse-definitions#ClaimResponse.addItem.detail.subDetail.tax)** [0..1]: [Money](/Money) Total tax - **[ClaimResponse.addItem.detail.subDetail.net](/claimresponse-definitions#ClaimResponse.addItem.detail.subDetail.net)** [0..1]: [Money](/Money) Total item cost - **[ClaimResponse.addItem.detail.subDetail.noteNumber](/claimresponse-definitions#ClaimResponse.addItem.detail.subDetail.noteNumber)** [0..*]: [positiveInt](/positiveInt) Applicable note numbers - **[ClaimResponse.addItem.detail.subDetail.reviewOutcome](/claimresponse-definitions#ClaimResponse.addItem.detail.subDetail.reviewOutcome)** [0..1]: - Added items subdetail level adjudication results - **[ClaimResponse.addItem.detail.subDetail.adjudication](/claimresponse-definitions#ClaimResponse.addItem.detail.subDetail.adjudication)** [0..*]: - Added items subdetail adjudication - **[ClaimResponse.adjudication](/claimresponse-definitions#ClaimResponse.adjudication)** [0..*]: - Header-level adjudication - **[ClaimResponse.total](/claimresponse-definitions#ClaimResponse.total)** [0..*]: [BackboneElement](/BackboneElement) Adjudication totals - **[ClaimResponse.total.category](/claimresponse-definitions#ClaimResponse.total.category)** [1..1]: [CodeableConcept](/CodeableConcept) example:[adjudication](/valueset-adjudication) Type of adjudication information - **[ClaimResponse.total.amount](/claimresponse-definitions#ClaimResponse.total.amount)** [1..1]: [Money](/Money) Financial total for the category - **[ClaimResponse.payment](/claimresponse-definitions#ClaimResponse.payment)** [0..1]: [BackboneElement](/BackboneElement) Payment Details - **[ClaimResponse.payment.type](/claimresponse-definitions#ClaimResponse.payment.type)** [1..1]: [CodeableConcept](/CodeableConcept) preferred:[ex-paymenttype](/valueset-ex-paymenttype) Partial or complete payment - **[ClaimResponse.payment.adjustment](/claimresponse-definitions#ClaimResponse.payment.adjustment)** [0..1]: [Money](/Money) Payment adjustment for non-claim issues - **[ClaimResponse.payment.adjustmentReason](/claimresponse-definitions#ClaimResponse.payment.adjustmentReason)** [0..1]: [CodeableConcept](/CodeableConcept) preferred:[payment-adjustment-reason](/valueset-payment-adjustment-reason) Explanation for the adjustment - **[ClaimResponse.payment.date](/claimresponse-definitions#ClaimResponse.payment.date)** [0..1]: [date](/date) Expected date of payment - **[ClaimResponse.payment.amount](/claimresponse-definitions#ClaimResponse.payment.amount)** [1..1]: [Money](/Money) Payable amount after adjustment - **[ClaimResponse.payment.identifier](/claimresponse-definitions#ClaimResponse.payment.identifier)** [0..1]: [Identifier](/Identifier) Business identifier for the payment - **[ClaimResponse.fundsReserve](/claimresponse-definitions#ClaimResponse.fundsReserve)** [0..1]: [CodeableConcept](/CodeableConcept) preferred:[fundsreserve](/valueset-fundsreserve) Funds reserved status - **[ClaimResponse.formCode](/claimresponse-definitions#ClaimResponse.formCode)** [0..1]: [CodeableConcept](/CodeableConcept) example:[forms](/valueset-forms) Printed form identifier - **[ClaimResponse.form](/claimresponse-definitions#ClaimResponse.form)** [0..1]: [Attachment](/Attachment) Printed reference or actual form - **[ClaimResponse.processNote](/claimresponse-definitions#ClaimResponse.processNote)** [0..*]: [BackboneElement](/BackboneElement) Note concerning adjudication - **[ClaimResponse.processNote.class](/claimresponse-definitions#ClaimResponse.processNote.class)** [0..1]: [CodeableConcept](/CodeableConcept) Business kind of note - **[ClaimResponse.processNote.number](/claimresponse-definitions#ClaimResponse.processNote.number)** [0..1]: [positiveInt](/positiveInt) Note instance identifier - **[ClaimResponse.processNote.type](/claimresponse-definitions#ClaimResponse.processNote.type)** [0..1]: [CodeableConcept](/CodeableConcept) extensible:[note-type](/valueset-note-type) Note purpose - **[ClaimResponse.processNote.text](/claimresponse-definitions#ClaimResponse.processNote.text)** [1..1]: [markdown](/markdown) Note explanatory text - **[ClaimResponse.processNote.language](/claimresponse-definitions#ClaimResponse.processNote.language)** [0..1]: [CodeableConcept](/CodeableConcept) required:[all-languages](/valueset-all-languages) Language of the text - **[ClaimResponse.communicationRequest](/claimresponse-definitions#ClaimResponse.communicationRequest)** [0..*]: Reference([CommunicationRequest](/CommunicationRequest)) Request for additional information - **[ClaimResponse.insurance](/claimresponse-definitions#ClaimResponse.insurance)** [0..*]: [BackboneElement](/BackboneElement) Patient insurance information - **[ClaimResponse.insurance.sequence](/claimresponse-definitions#ClaimResponse.insurance.sequence)** [1..1]: [positiveInt](/positiveInt) Insurance instance identifier - **[ClaimResponse.insurance.focal](/claimresponse-definitions#ClaimResponse.insurance.focal)** [1..1]: [boolean](/boolean) Coverage to be used for adjudication - **[ClaimResponse.insurance.coverage](/claimresponse-definitions#ClaimResponse.insurance.coverage)** [1..1]: Reference([Coverage](/Coverage)) Insurance information - **[ClaimResponse.insurance.businessArrangement](/claimresponse-definitions#ClaimResponse.insurance.businessArrangement)** [0..1]: [string](/string) Additional provider contract number - **[ClaimResponse.insurance.claimResponse](/claimresponse-definitions#ClaimResponse.insurance.claimResponse)** [0..1]: Reference([ClaimResponse](/ClaimResponse)) Adjudication results - **[ClaimResponse.error](/claimresponse-definitions#ClaimResponse.error)** [0..*]: [BackboneElement](/BackboneElement) Processing errors - **[ClaimResponse.error.itemSequence](/claimresponse-definitions#ClaimResponse.error.itemSequence)** [0..1]: [positiveInt](/positiveInt) Item sequence number - **[ClaimResponse.error.detailSequence](/claimresponse-definitions#ClaimResponse.error.detailSequence)** [0..1]: [positiveInt](/positiveInt) Detail sequence number - **[ClaimResponse.error.subDetailSequence](/claimresponse-definitions#ClaimResponse.error.subDetailSequence)** [0..1]: [positiveInt](/positiveInt) Subdetail sequence number - **[ClaimResponse.error.code](/claimresponse-definitions#ClaimResponse.error.code)** [1..1]: [CodeableConcept](/CodeableConcept) example:[adjudication-error](/valueset-adjudication-error) Error code detailing processing issues - **[ClaimResponse.error.expression](/claimresponse-definitions#ClaimResponse.error.expression)** [0..*]: [string](/string) FHIRPath of element(s) related to issue ## Mappings - [ClaimResponse Mappings](/claimresponse-mappings) — 34 mapping entries ## Resource Packs ### list-ClaimResponse-packs.xml ```xml ``` ## Search Parameters - [created](/claimresponse-search#created) — **date** — The creation date — `ClaimResponse.created` - [disposition](/claimresponse-search#disposition) — **string** — The contents of the disposition message — `ClaimResponse.disposition` - [group](/claimresponse-search#group) — **reference** — The subject of care — `ClaimResponse.subject.where(resolve() is Group) | ClaimResponse.addItem.subject.where(resolve() is Group)` - [identifier](/claimresponse-search#identifier) — **token** — The identity of the ClaimResponse — `ClaimResponse.identifier` - [insurer](/claimresponse-search#insurer) — **reference** — The organization which generated this resource — `ClaimResponse.insurer` - [outcome](/claimresponse-search#outcome) — **token** — The processing outcome — `ClaimResponse.outcome` - [patient](/claimresponse-search#patient) — **reference** — The subject of care — `ClaimResponse.subject.where(resolve() is Patient) | ClaimResponse.addItem.subject.where(resolve() is Patient)` - [payment-date](/claimresponse-search#payment-date) — **date** — The expected payment date — `ClaimResponse.payment.date` - [request](/claimresponse-search#request) — **reference** — The claim reference — `ClaimResponse.request` - [requestor](/claimresponse-search#requestor) — **reference** — The Provider of the claim — `ClaimResponse.requestor` - [status](/claimresponse-search#status) — **token** — The status of the ClaimResponse — `ClaimResponse.status` - [subject](/claimresponse-search#subject) — **reference** — Subject receiving the products or services — `ClaimResponse.subject | ClaimResponse.addItem.subject` - [use](/claimresponse-search#use) — **token** — The type of claim — `ClaimResponse.use` [Full Search Parameters](/claimresponse-search) ## Examples - [claimresponse-example](/claimresponse-example-claimresponse-example) — claimresponse-example - [claimresponse-example-2](/claimresponse-example-claimresponse-example-2) — claimresponse-example-2 - [claimresponse-example-additem](/claimresponse-example-claimresponse-example-additem) — claimresponse-example-additem - [claimresponse-example-unsolicited-preauth](/claimresponse-example-claimresponse-example-unsolicited-preauth) — claimresponse-example-unsolicited-preauth - [claimresponse-example-vision-3tier](/claimresponse-example-claimresponse-example-vision-3tier) — claimresponse-example-vision-3tier - [claimresponse-examples-header](/claimresponse-example-claimresponse-examples-header) — claimresponse-examples-header - [R3500](/claimresponse-example-R3500) — claimresponse-example — General Person Primary Coverage Example - [R3501](/claimresponse-example-R3501) — claimresponse-example-2 — A ClaimResponse for a Claim that contains processing errors - [R3502](/claimresponse-example-R3502) — claimresponse-example-vision-3tier — Primary insurance response to a 3Tier Vision Claim - [R3503](/claimresponse-example-R3503) — claimresponse-example-additem — A ClaimResponse demonstrating payer service code substitutions - [UR3503](/claimresponse-example-UR3503) — claimresponse-example-unsolicited-preauth — Unsolicited Pre-Authorization for social Dental Services [Full Examples](/claimresponse-examples) ## Mapping Exceptions ### claimresponse-event-mapping-exceptions.xml ### Divergent Elements - **Event.identifier** → **ClaimResponse.identifier** - summary | reason=Unknown | pattern=true - shortUnmatched | reason=Unknown | pattern=Business identifier for claim response | resource=Business Identifier for a claim response - definitionUnmatched | reason=Unknown | pattern=Business identifiers assigned to this claim response by the performer and/or other systems. These identifiers remain constant as the resource is updated and propagates from server to server. | resource=A unique identifier assigned to this claim response. - commentsUnmatched | reason=Unknown | pattern=Note: This is a business identifier, not a resource identifier (see [discussion](resource.html#identifiers)). It is best practice for the identifier to only appear on a single resource instance, however business practices may occasionally dictate that multiple resource instances with the same identifier can exist - possibly even with different resource types. For example, multiple Patient and a Person resource instance might share the same social insurance number. - requirementsUnmatched | reason=Unknown | pattern=Allows identification of the claim response as it is known by various participating systems and in a way that remains consistent across servers. | resource=Allows claim responses to be distinguished and referenced. - **Event.basedOn** → **ClaimResponse.request** - missingTypes | reason=Unknown | pattern=Reference(Request) - extraTypes | reason=Unknown - shortUnmatched | reason=Unknown | pattern=Fulfills plan, proposal or order | resource=Id of resource triggering adjudication - definitionUnmatched | reason=Unknown | pattern=A plan, proposal or order that is fulfilled in whole or in part by this claim response. | resource=Original request resource reference. - requirementsUnmatched | reason=Unknown | pattern=Allows tracing of authorization for the claim response and tracking whether proposals/recommendations were acted upon. - **Event.status** → **ClaimResponse.status** - shortUnmatched | reason=Unknown | pattern=preparation | in-progress | not-done | suspended | aborted | completed | entered-in-error | unknown | resource=active | cancelled | draft | entered-in-error - definitionUnmatched | reason=Unknown | pattern=The current state of the claim response. | resource=The status of the resource instance. - commentsUnmatched | reason=Unknown | pattern=A nominal state-transition diagram can be found in the (Event pattern documentation Unknown does not represent "other" - one of the defined statuses must apply. Unknown is used when the authoring system is not sure what the current status is. | resource=This element is labeled as a modifier because the status contains codes that mark the resource as not currently valid. - **Event.occurrence[x]** → **ClaimResponse.created** - missingTypes | reason=Unknown | pattern=Period, Timing - shortUnmatched | reason=Unknown | pattern=When claim response occurred/is occurring | resource=Response creation date - definitionUnmatched | reason=Unknown | pattern=The date, period or timing when the claim response did occur or is occurring. | resource=The date this resource was created. - commentsUnmatched | reason=Unknown | pattern=This indicates when the activity actually occurred or is occurring, not when it was asked/requested/ordered to occur. For the latter, look at the occurence element of the Request this {{event}} is "basedOn". The status code allows differentiation of whether the timing reflects a historic event or an ongoing event. Ongoing events should not include an upper bound in the Period or Timing.bounds. . - **Event.performer** → **ClaimResponse.insurer** - extraTypes | reason=Unknown - shortUnmatched | reason=Unknown | pattern=Who performed claim response and what they did | resource=Party responsible for reimbursement - definitionUnmatched | reason=Unknown | pattern=Indicates who or what performed the claim response and how they were involved. | resource=The party responsible for authorization, adjudication and reimbursement. - **Event.note** → **ClaimResponse.disposition** - missingTypes | reason=Unknown | pattern=Annotation - extraTypes | reason=Unknown - shortUnmatched | reason=Unknown | pattern=Comments made about the event | resource=Disposition Message - definitionUnmatched | reason=Unknown | pattern=Comments made about the claim response by the performer, subject or other participants. | resource=A human readable description of the status of the adjudication. ### Unmapped Elements - **Event.partOf** — Unknown - **Event.reported** — Unknown - **Event.reason** — Unknown - **Event.relevantHistory** — Unknown - **Event.code** — Unknown - **Event.location** — Unknown - **Event.subject** — Unknown - **Event.statusReason** — Unknown - **Event.performer.actor** — Unknown - **Event.performer.function** — Unknown - **Event.category** — Unknown - **Event.encounter** — Unknown - **Event.recorded** — Unknown - **Event.product** — Unknown - **Event.researchStudy** — Unknown ### claimresponse-fivews-mapping-exceptions.xml ### Unmapped Elements - **FiveWs.what** — Unknown - **FiveWs.author** — Unknown - **FiveWs.actor** — Unknown - **FiveWs.cause** — Unknown - **FiveWs.version** — Unknown - **FiveWs.witness** — Unknown - **FiveWs.context** — Unknown - **FiveWs.init** — Unknown - **FiveWs.who** — Unknown - **FiveWs.grade** — Unknown - **FiveWs.planned** — Unknown ### claimresponse-request-mapping-exceptions.xml ### Divergent Elements - **Request.supportingInfo** → **ClaimResponse.supportingInfo** - missingTypes | reason=Unknown | pattern=Reference(Any) - extraTypes | reason=Unknown - shortUnmatched | reason=Unknown | pattern=Extra information to use in performing request | resource=Supporting information - definitionUnmatched | reason=Unknown | pattern=Information that may be needed by/relevant to the performer in their execution of this claim response. | resource=Additional information codes regarding exceptions, special considerations, the condition, situation, prior or concurrent issues. - commentsUnmatched | reason=Unknown | pattern=See guidance on [notes vs. supportingInfo](request.html#notes). | resource=Often there are multiple jurisdiction specific valuesets which are required. ### Unmapped Elements - **Request.intent** — Unknown - **Request.insurance** — Unknown - **Request.priority** — Unknown - **Request.subject** — Unknown - **Request.occurrence** — Unknown - **Request.status** — Unknown - **Request.groupIdentifier** — Unknown - **Request.deliverTo** — Unknown - **Request.replaces** — Unknown - **Request.note** — Unknown - **Request.basedOn** — Unknown - **Request.encounter** — Unknown - **Request.performer** — Unknown - **Request.requester** — Unknown - **Request.category** — Unknown - **Request.reason** — Unknown - **Request.identifier** — Unknown - **Request.authoredOn** — Unknown - **Request.reported** — Unknown - **Request.relevantHistory** — Unknown - **Request.code** — Unknown - **Request.statusReason** — Unknown - **Request.performerType** — Unknown - **Request.doNotPerform** — Unknown - **Request.product** — Unknown