type: resource-definitionsresource: ClaimResponse

ClaimResponse Definitions

ClaimResponse

Response to a claim predetermination or preauthorization

Definition: This resource provides the adjudication details from the processing of a Claim resource.

Aliases: Remittance Advice

Cardinality: 0..*

Mappings: workflow=Event; w5=financial.billing

ClaimResponse.identifier

Business Identifier for a claim response

Definition: A unique identifier assigned to this claim response.

Requirements: Allows claim responses to be distinguished and referenced.

Cardinality: 0..*

Type: Identifier

Mappings: workflow=Event.identifier; w5=FiveWs.identifier

ClaimResponse.traceNumber

Number for tracking

Definition: Trace number for tracking purposes. May be defined at the jurisdiction level or between trading partners.

Requirements: Allows partners to uniquely identify components for tracking.

Cardinality: 0..*

Type: Identifier

ClaimResponse.status

active | cancelled | draft | entered-in-error

Definition: The status of the resource instance.

Comments: This element is labeled as a modifier because the status contains codes that mark the resource as not currently valid.

Requirements: Need to track the status of the resource as 'draft' resources may undergo further edits while 'active' resources are immutable and may only have their status changed to 'cancelled'.

Cardinality: 1..1

Type: code

Binding: required:fm-status

Summary: true

Is Modifier: true (Reason: This element is labeled as a modifier because it is a status element that contains status entered-in-error which means that the resource should not be treated as valid)

Mappings: workflow=Event.status; w5=FiveWs.status

ClaimResponse.statusReason

Reason for status change

Definition: Used to indicate why the status has changed.

Comments: Implementation guides may consider adding invariants such that if status = cancelled, statusReason SHALL be supplied.

Requirements: This is used to implement conformance on other elements.

Cardinality: 0..1

Type: string

Summary: true

ClaimResponse.type

More granular claim type

Definition: A finer grained suite of claim type codes which may convey additional information such as Inpatient vs Outpatient and/or a specialty service.

Comments: This may contain the local bill type codes, for example the US UB-04 bill type code or the CMS bill type.

Requirements: Some jurisdictions need a finer grained claim type for routing and adjudication.

Cardinality: 1..1

Type: CodeableConcept

Binding: extensible:claim-type

Summary: true

Mappings: w5=FiveWs.class

ClaimResponse.subType

More granular claim type

Definition: A finer grained suite of claim type codes which may convey additional information such as Inpatient vs Outpatient and/or a specialty service.

Comments: This may contain the local bill type codes, for example the US UB-04 bill type code or the CMS bill type.

Requirements: Some jurisdictions need a finer grained claim type for routing and adjudication.

Cardinality: 0..1

Type: CodeableConcept

Binding: example:claim-subtype

Mappings: w5=FiveWs.class

ClaimResponse.use

claim | preauthorization | predetermination

Definition: A code to indicate whether the nature of the request is: Claim - A request to an Insurer to adjudicate the supplied charges for health care goods and services under the identified policy and to pay the determined Benefit amount, if any; Preauthorization - A request to an Insurer to adjudicate the supplied proposed future charges for health care goods and services under the identified policy and to approve the services and provide the expected benefit amounts and potentially to reserve funds to pay the benefits when Claims for the indicated services are later submitted; or, Pre-determination - A request to an Insurer to adjudicate the supplied 'what if' charges for health care goods and services under the identified policy and report back what the Benefit payable would be had the services actually been provided.

Requirements: This element is required to understand the nature of the request for adjudication.

Cardinality: 1..1

Type: code

Binding: required:claim-use

Summary: true

Mappings: w5=FiveWs.class

ClaimResponse.subject

The recipient(s) of the products and services

Definition: The party/group to whom the professional services and/or products have been supplied or are being considered and for whom actual for facast reimbursement is sought.

Requirements: The patient must be supplied to the insurer so that confirmation of coverage and service hstory may be considered as part of the authorization and/or adjudiction.

Aliases: patient

Cardinality: 1..1

Type: Reference(Patient, Group)

Summary: true

Mappings: w5=FiveWs.subject

ClaimResponse.created

Response creation date

Definition: The date this resource was created.

Requirements: Need to record a timestamp for use by both the recipient and the issuer.

Cardinality: 1..1

Type: dateTime

Summary: true

Mappings: workflow=Event.occurrence[x]; w5=FiveWs.recorded

ClaimResponse.insurer

Party responsible for reimbursement

Definition: The party responsible for authorization, adjudication and reimbursement.

Requirements: To be a valid claim, preauthorization or predetermination there must be a party who is responsible for adjudicating the contents against a policy which provides benefits for the patient.

Cardinality: 0..1

Type: Reference(Organization)

Summary: true

Mappings: workflow=Event.performer

ClaimResponse.requestor

Party responsible for the claim

Definition: The provider which is responsible for the claim, predetermination or preauthorization.

Comments: Typically this field would be 1..1 where this party is accountable for the data content within the claim but is not necessarily the facility, provider group or practitioner who provided the products and services listed within this claim resource. This field is the Billing Provider, for example, a facility, provider group, lab or practitioner..

Cardinality: 0..1

Type: Reference(Practitioner, PractitionerRole, Organization)

Mappings: w5=FiveWs.source

ClaimResponse.request

Id of resource triggering adjudication

Definition: Original request resource reference.

Cardinality: 0..1

Type: Reference(Claim)

Summary: true

Mappings: workflow=Event.basedOn; w5=FiveWs.why[x]

ClaimResponse.outcome

queued | complete | error | partial

Definition: The outcome of the claim, predetermination, or preauthorization processing.

Comments: The resource may be used to indicate that the Claim/Preauthorization/Pre-determination has been received but processing has not begun (queued); that it has been processed and one or more errors have been detected (error); no errors were detected and some of the adjudication processing has been performed (partial); or all of the adjudication processing has completed without errors (complete).

Requirements: To advise the requestor of an overall processing outcome.

Cardinality: 1..1

Type: code

Binding: required:claim-outcome

Summary: true

ClaimResponse.decision

Result of the adjudication

Definition: The result of the claim, predetermination, or preauthorization adjudication.

Comments: The element is used to indicate the current state of the adjudication overall for the claim resource, for example: the request has been held (pended) for adjudication processing, for manual review or other reasons; that it has been processed and will be paid, or the outstanding paid, as submitted (approved); that no amount will be paid (denied); or that some amount between zero and the submitted amount will be paid (partial).

Requirements: To advise the requestor of the result of the adjudication process.

Cardinality: 0..1

Type: CodeableConcept

Binding: preferred:claim-decision

Summary: true

ClaimResponse.disposition

Disposition Message

Definition: A human readable description of the status of the adjudication.

Requirements: Provided for user display.

Cardinality: 0..1

Type: string

Mappings: workflow=Event.note

ClaimResponse.preAuthRef

Preauthorization reference

Definition: Reference from the Insurer which is used in later communications which refers to this adjudication.

Comments: This value is only present on preauthorization adjudications.

Requirements: On subsequent claims, the insurer may require the provider to quote this value.

Cardinality: 0..1

Type: string

ClaimResponse.preAuthPeriod

Preauthorization reference effective period

Definition: The time frame during which this authorization is effective.

Requirements: To convey to the provider when the authorized products and services must be supplied for the authorized adjudication to apply.

Cardinality: 0..1

Type: Period

ClaimResponse.event

Event information

Definition: Information code for an event with a corresponding date or period.

Cardinality: 0..*

Type: BackboneElement

ClaimResponse.event.type

Specific event

Definition: A coded event such as when a service is expected or a card printed.

Cardinality: 1..1

Type: CodeableConcept

Binding: example:datestype

ClaimResponse.event.when[x]

Occurance date or period

Definition: A date or period in the past or future indicating when the event occurred or is expectd to occur.

Cardinality: 1..1

Type: dateTime, Period

ClaimResponse.payeeType

Party to be paid any benefits payable

Definition: Type of Party to be reimbursed: subscriber, billing provider, other.

Requirements: Need to know who should receive payment with the most common situations being the billing Provider (assignment of benefits) or the Subscriber.

Cardinality: 0..1

Type: CodeableConcept

Binding: example:payeetype

ClaimResponse.encounter

Encounters associated with the listed treatments

Definition: Healthcare encounters related to this claim.

Comments: This will typically be the encounter the event occurred within, but some activities may be initiated prior to or after the official completion of an encounter but still be tied to the context of the encounter.

Requirements: Used in some jurisdictions to link clinical events to claim items.

Cardinality: 0..*

Type: Reference(Encounter)

ClaimResponse.diagnosisRelatedGroup

Package billing code

Definition: A package billing code or bundle code used to group products and services to a particular health condition (such as heart attack) which is based on a predetermined grouping code system.

Comments: For example DRG (Diagnosis Related Group) or a bundled billing code. A patient may have a diagnosis of a Myocardial Infarction and a DRG for HeartAttack would be assigned. The Claim item (and possible subsequent claims) would refer to the DRG for those line items that were for services related to the heart attack event.

Requirements: Required to relate the current diagnosis to a package billing code that is then referenced on the individual claim items which are specific to the health condition covered by the package code.

Cardinality: 0..1

Type: CodeableConcept

Binding: example:ex-diagnosisrelatedgroup

ClaimResponse.supportingInfo

Supporting information

Definition: Additional information codes regarding exceptions, special considerations, the condition, situation, prior or concurrent issues.

Comments: Often there are multiple jurisdiction specific valuesets which are required.

Requirements: Typically these information codes are required to support the services rendered or the adjudication of the services rendered.

Aliases: Attachments Exception Codes Occurrence Codes Value codes

Cardinality: 0..*

Type: BackboneElement

Mappings: workflow=Request.supportingInfo

ClaimResponse.supportingInfo.sequence

Information instance identifier

Definition: A number to uniquely identify supporting information entries.

Requirements: Necessary to maintain the order of the supporting information items and provide a mechanism to link to claim details.

Cardinality: 1..1

Type: positiveInt

ClaimResponse.supportingInfo.category

Classification of the supplied information

Definition: The general class of the information supplied: information; exception; accident, employment; onset, etc.

Comments: This may contain a category for the local bill type codes.

Requirements: Required to group or associate information items with common characteristics. For example: admission information or prior treatments.

Cardinality: 1..1

Type: CodeableConcept

Binding: preferred:claim-informationcategory

ClaimResponse.supportingInfo.code

Type of information

Definition: System and code pertaining to the specific information regarding special conditions relating to the setting, treatment or patient for which care is sought.

Requirements: Required to identify the kind of additional information.

Cardinality: 0..1

Type: CodeableConcept

Binding: example:claim-exception

ClaimResponse.supportingInfo.timing[x]

When it occurred

Definition: The date when or period to which this information refers.

Cardinality: 0..1

Type: dateTime, Period, Timing

ClaimResponse.supportingInfo.value[x]

Data to be provided

Definition: Additional data or information such as resources, documents, images etc. including references to the data or the actual inclusion of the data.

Comments: Could be used to provide references to other resources, document. For example could contain a PDF in an Attachment of the Police Report for an Accident.

Requirements: To convey the data content to be provided when the information is more than a simple code or period.

Cardinality: 0..1

Type: *

ClaimResponse.supportingInfo.reason

Explanation for the information

Definition: Provides the reason in the situation where a reason code is required in addition to the content.

Comments: For example: the reason for the additional stay, or why a tooth is missing.

Requirements: Needed when the supporting information has both a date and amount/value and requires explanation.

Cardinality: 0..1

Type: CodeableConcept

Binding: example:missing-tooth-reason

ClaimResponse.item

Adjudication for claim line items

Definition: A claim line. Either a simple (a product or service) or a 'group' of details which can also be a simple items or groups of sub-details.

Requirements: The adjudication for items provided on the claim.

Cardinality: 0..*

Type: BackboneElement

ClaimResponse.item.itemSequence

Claim item instance identifier

Definition: A number to uniquely reference the claim item entries.

Requirements: Necessary to provide a mechanism to link the adjudication result to the submitted claim item.

Cardinality: 1..1

Type: positiveInt

ClaimResponse.item.traceNumber

Number for tracking

Definition: Trace number for tracking purposes. May be defined at the jurisdiction level or between trading partners.

Requirements: Allows partners to uniquely identify components for tracking.

Cardinality: 0..*

Type: Identifier

ClaimResponse.item.informationSequence

Applicable exception and supporting information

Definition: Exceptions, special conditions and supporting information applicable for this service or product.

Requirements: Need to reference the supporting information items that relate directly to this product or service.

Cardinality: 0..*

Type: positiveInt

ClaimResponse.item.noteNumber

Applicable note numbers

Definition: The numbers associated with notes below which apply to the adjudication of this item.

Requirements: Provides a condensed manner for associating human readable descriptive explanations for adjudications on the line item.

Cardinality: 0..*

Type: positiveInt

ClaimResponse.item.reviewOutcome

Adjudication results

Definition: The high-level results of the adjudication if adjudication has been performed.

Cardinality: 0..1

Type: BackboneElement

ClaimResponse.item.reviewOutcome.decision

Result of the adjudication

Definition: The result of the claim, predetermination, or preauthorization adjudication.

Requirements: To advise the requestor of the result of the adjudication process.

Cardinality: 0..1

Type: CodeableConcept

Binding: preferred:claim-decision

ClaimResponse.item.reviewOutcome.reason

Reason for result of the adjudication

Definition: The reasons for the result of the claim, predetermination, or preauthorization adjudication.

Requirements: To advise the requestor of the contributors to the result of the adjudication process.

Cardinality: 0..*

Type: CodeableConcept

Binding: example:claim-decision-reason

ClaimResponse.item.reviewOutcome.preAuthRef

Preauthorization reference

Definition: Reference from the Insurer which is used in later communications which refers to this adjudication.

Comments: This value is only present on preauthorization adjudications.

Requirements: On subsequent claims, the insurer may require the provider to quote this value.

Cardinality: 0..1

Type: string

ClaimResponse.item.reviewOutcome.preAuthPeriod

Preauthorization reference effective period

Definition: The time frame during which this authorization is effective.

Requirements: To convey to the provider when the authorized products and services must be supplied for the authorized adjudication to apply.

Cardinality: 0..1

Type: Period

ClaimResponse.item.adjudication

Adjudication details

Definition: If this item is a group then the values here are a summary of the adjudication of the detail items. If this item is a simple product or service then this is the result of the adjudication of this item.

Requirements: The adjudication results conveys the insurer's assessment of the item provided in the claim under the terms of the patient's insurance coverage.

Cardinality: 0..*

Type: BackboneElement

ClaimResponse.item.adjudication.category

Type of adjudication information

Definition: A code to indicate the information type of this adjudication record. Information types may include the value submitted, maximum values or percentages allowed or payable under the plan, amounts that: the patient is responsible for in aggregate or pertaining to this item; amounts paid by other coverages; and, the benefit payable for this item.

Comments: For example codes indicating: Co-Pay, deductible, eligible, benefit, tax, etc.

Requirements: Needed to enable understanding of the context of the other information in the adjudication.

Cardinality: 1..1

Type: CodeableConcept

Binding: preferred:adjudication

ClaimResponse.item.adjudication.reason

Explanation of adjudication outcome

Definition: A code supporting the understanding of the adjudication result and explaining variance from expected amount.

Comments: For example may indicate that the funds for this benefit type have been exhausted.

Requirements: To support understanding of variance from adjudication expectations.

Cardinality: 0..1

Type: CodeableConcept

Binding: example:adjudication-reason

ClaimResponse.item.adjudication.amount

Monetary amount

Definition: Monetary amount associated with the category.

Comments: For example: amount submitted, eligible amount, co-payment, and benefit payable.

Requirements: Most adjudication categories convey a monetary amount.

Cardinality: 0..1

Type: Money

ClaimResponse.item.adjudication.quantity

Non-monetary value

Definition: A non-monetary value associated with the category. Mutually exclusive to the amount element above.

Comments: For example: eligible percentage or co-payment percentage.

Requirements: Some adjudication categories convey a percentage or a fixed value.

Cardinality: 0..1

Type: Quantity

ClaimResponse.item.adjudication.decisionDate

When was adjudication performed

Definition: The date and time the adjudication decision occured.

Comments: Implementation Guide authors may choose to require this element based on local regulatory requirements.

Cardinality: 0..1

Type: dateTime

ClaimResponse.item.detail

Adjudication for claim details

Definition: A claim detail. Either a simple (a product or service) or a 'group' of sub-details which are simple items.

Requirements: The adjudication for details provided on the claim.

Cardinality: 0..*

Type: BackboneElement

ClaimResponse.item.detail.detailSequence

Claim detail instance identifier

Definition: A number to uniquely reference the claim detail entry.

Requirements: Necessary to provide a mechanism to link the adjudication result to the submitted claim detail.

Cardinality: 1..1

Type: positiveInt

ClaimResponse.item.detail.traceNumber

Number for tracking

Definition: Trace number for tracking purposes. May be defined at the jurisdiction level or between trading partners.

Requirements: Allows partners to uniquely identify components for tracking.

Cardinality: 0..*

Type: Identifier

ClaimResponse.item.detail.noteNumber

Applicable note numbers

Definition: The numbers associated with notes below which apply to the adjudication of this item.

Requirements: Provides a condensed manner for associating human readable descriptive explanations for adjudications on the line item.

Cardinality: 0..*

Type: positiveInt

ClaimResponse.item.detail.reviewOutcome

Detail level adjudication results

Definition: The high-level results of the adjudication if adjudication has been performed.

Cardinality: 0..1

ClaimResponse.item.detail.adjudication

Detail level adjudication details

Definition: The adjudication results.

Cardinality: 0..*

ClaimResponse.item.detail.subDetail

Adjudication for claim sub-details

Definition: A sub-detail adjudication of a simple product or service.

Requirements: The adjudication for sub-details provided on the claim.

Cardinality: 0..*

Type: BackboneElement

ClaimResponse.item.detail.subDetail.subDetailSequence

Claim sub-detail instance identifier

Definition: A number to uniquely reference the claim sub-detail entry.

Requirements: Necessary to provide a mechanism to link the adjudication result to the submitted claim sub-detail.

Cardinality: 1..1

Type: positiveInt

ClaimResponse.item.detail.subDetail.traceNumber

Number for tracking

Definition: Trace number for tracking purposes. May be defined at the jurisdiction level or between trading partners.

Requirements: Allows partners to uniquely identify components for tracking.

Cardinality: 0..*

Type: Identifier

ClaimResponse.item.detail.subDetail.noteNumber

Applicable note numbers

Definition: The numbers associated with notes below which apply to the adjudication of this item.

Requirements: Provides a condensed manner for associating human readable descriptive explanations for adjudications on the line item.

Cardinality: 0..*

Type: positiveInt

ClaimResponse.item.detail.subDetail.reviewOutcome

Subdetail level adjudication results

Definition: The high-level results of the adjudication if adjudication has been performed.

Cardinality: 0..1

ClaimResponse.item.detail.subDetail.adjudication

Subdetail level adjudication details

Definition: The adjudication results.

Cardinality: 0..*

ClaimResponse.addItem

Insurer added line items

Definition: The first-tier service adjudications for payer added product or service lines.

Requirements: Insurers may redefine the provided product or service or may package and/or decompose groups of products and services. The addItems allows the insurer to provide their line item list with linkage to the submitted items/details/sub-details. In a preauthorization the insurer may use the addItem structure to provide additional information on authorized products and services.

Cardinality: 0..*

Type: BackboneElement

ClaimResponse.addItem.itemSequence

Item sequence number

Definition: Claim items which this service line is intended to replace.

Requirements: Provides references to the claim items.

Cardinality: 0..*

Type: positiveInt

ClaimResponse.addItem.detailSequence

Detail sequence number

Definition: The sequence number of the details within the claim item which this line is intended to replace.

Requirements: Provides references to the claim details within the claim item.

Cardinality: 0..*

Type: positiveInt

ClaimResponse.addItem.subdetailSequence

Subdetail sequence number

Definition: The sequence number of the sub-details within the details within the claim item which this line is intended to replace.

Requirements: Provides references to the claim sub-details within the claim detail.

Cardinality: 0..*

Type: positiveInt

ClaimResponse.addItem.traceNumber

Number for tracking

Definition: Trace number for tracking purposes. May be defined at the jurisdiction level or between trading partners.

Requirements: Allows partners to uniquely identify components for tracking.

Cardinality: 0..*

Type: Identifier

ClaimResponse.addItem.subject

The recipient of the products and services

Definition: The party to whom the professional services and/or products have been supplied or are being considered and for whom actual for facast reimbursement is sought.

Comments: Profilers should consider making this element required when the backbone .subject is a group.

Cardinality: 0..1

Type: Reference(Patient, Group)

ClaimResponse.addItem.informationSequence

Applicable exception and supporting information

Definition: Exceptions, special conditions and supporting information applicable for this service or product.

Requirements: Need to reference the supporting information items that relate directly to this product or service.

Cardinality: 0..*

Type: positiveInt

ClaimResponse.addItem.provider

Authorized providers

Definition: The providers who are authorized for the services rendered to the patient.

Requirements: Insurer may provide authorization specifically to a restricted set of providers rather than an open authorization.

Cardinality: 0..*

Type: Reference(Practitioner, PractitionerRole, Organization)

Mappings: w5=FiveWs.source

ClaimResponse.addItem.revenue

Revenue or cost center code

Definition: The type of revenue or cost center providing the product and/or service.

Requirements: Needed in the processing of institutional claims.

Cardinality: 0..1

Type: CodeableConcept

Binding: example:ex-revenue-center

ClaimResponse.addItem.category

Benefit classification

Definition: Code to identify the general type of benefits under which products and services are provided.

Comments: Examples include Medical Care, Periodontics, Renal Dialysis, Vision Coverage.

Requirements: Needed in the processing of institutional claims as this allows the insurer to determine whether a facial X-Ray is for dental, orthopedic, or facial surgery purposes.

Cardinality: 0..1

Type: CodeableConcept

Binding: example:ex-benefitcategory

ClaimResponse.addItem.productOrService

Billing, service, product, or drug code

Definition: When the value is a group code then this item collects a set of related item details, otherwise this contains the product, service, drug or other billing code for the item. This element may be the start of a range of .productOrService codes used in conjunction with .productOrServiceEnd or it may be a solo element where .productOrServiceEnd is not used.

Comments: If this is an actual service or product line, i.e. not a Group, then use code to indicate the Professional Service or Product supplied (e.g. CTP, HCPCS, USCLS, ICD10, NCPDP, DIN, RxNorm, ACHI, CCI). If a grouping item then use a group code to indicate the type of thing being grouped e.g. 'glasses' or 'compound'.

Requirements: Necessary to state what was provided or done.

Cardinality: 0..1

Type: CodeableConcept

Binding: example:service-uscls

ClaimResponse.addItem.productOrServiceEnd

End of a range of codes

Definition: This contains the end of a range of product, service, drug or other billing codes for the item. This element is not used when the .productOrService is a group code. This value may only be present when a .productOfService code has been provided to convey the start of the range. Typically this value may be used only with preauthorizations and not with claims.

Aliases: End of a range of Drug Code; Bill Code; Service Code

Cardinality: 0..1

Type: CodeableConcept

Binding: example:service-uscls

ClaimResponse.addItem.request

Request or Referral for Service

Definition: Request or Referral for Goods or Service to be rendered.

Requirements: May identify the service to be provided or provider authorization for the service.

Cardinality: 0..*

Type: Reference(DeviceRequest, MedicationRequest, NutritionOrder, ServiceRequest, VisionPrescription)

ClaimResponse.addItem.modifier

Service/Product billing modifiers

Definition: Item typification or modifiers codes to convey additional context for the product or service.

Comments: For example in Oral whether the treatment is cosmetic or associated with TMJ, or for Medical whether the treatment was outside the clinic or outside of office hours.

Requirements: To support inclusion of the item for adjudication or to charge an elevated fee.

Cardinality: 0..*

Type: CodeableConcept

Binding: example:claim-modifiers

Mappings: rim=24.C, 24.D mods

ClaimResponse.addItem.programCode

Program the product or service is provided under

Definition: Identifies the program under which this may be recovered.

Comments: For example: Neonatal program, child dental program or drug users recovery program.

Requirements: Commonly used in in the identification of publicly provided program focused on population segments or disease classifications.

Cardinality: 0..*

Type: CodeableConcept

Binding: example:ex-program-code

Mappings: rim=24.H

ClaimResponse.addItem.serviced[x]

Date or dates of service or product delivery

Definition: The date or dates when the service or product was supplied, performed or completed.

Requirements: Needed to determine whether the service or product was provided during the term of the insurance coverage.

Cardinality: 0..1

Type: date, Period

Mappings: w5=FiveWs.done[x]; rim=24.A

ClaimResponse.addItem.location[x]

Place of service or where product was supplied

Definition: Where the product or service was provided.

Requirements: The location can alter whether the item was acceptable for insurance purposes or impact the determination of the benefit amount.

Cardinality: 0..1

Type: CodeableConcept, Address, Reference(Location)

Binding: example:service-place

Mappings: w5=FiveWs.where[x]; rim=24.B

ClaimResponse.addItem.quantity

Count of products or services

Definition: The number of repetitions of a service or product.

Requirements: Required when the product or service code does not convey the quantity provided.

Cardinality: 0..1

Type: Quantity(SimpleQuantity)

Mappings: rim=24.G

ClaimResponse.addItem.unitPrice

Fee, charge or cost per item

Definition: If the item is not a group then this is the fee for the product or service, otherwise this is the total of the fees for the details of the group.

Requirements: The amount charged to the patient by the provider for a single unit.

Cardinality: 0..1

Type: Money

ClaimResponse.addItem.factor

Price scaling factor

Definition: A real number that represents a multiplier used in determining the overall value of services delivered and/or goods received. The concept of a Factor allows for a discount or surcharge multiplier to be applied to a monetary amount.

Comments: To show a 10% senior's discount, the value entered is: 0.90 (1.00 - 0.10).

Requirements: When discounts are provided to a patient (example: Senior's discount) then this must be documented for adjudication.

Cardinality: 0..1

Type: decimal

ClaimResponse.addItem.tax

Total tax

Definition: The total of taxes applicable for this product or service.

Requirements: Required when taxes are not embedded in the unit price or provided as a separate service.

Cardinality: 0..1

Type: Money

ClaimResponse.addItem.net

Total item cost

Definition: The total amount claimed for the group (if a grouper) or the addItem. Net = unit price * quantity * factor.

Comments: For example, the formula: quantity * unitPrice * factor = net. Quantity and factor are assumed to be 1 if not supplied.

Requirements: Provides the total amount claimed for the group (if a grouper) or the line item.

Cardinality: 0..1

Type: Money

Mappings: rim=24.F

ClaimResponse.addItem.bodySite

Anatomical location

Definition: Physical location where the service is performed or applies.

Cardinality: 0..*

Type: BackboneElement

ClaimResponse.addItem.bodySite.site

Location

Definition: Physical service site on the patient (limb, tooth, etc.).

Comments: For example: Providing a tooth code allows an insurer to identify a provider performing a filling on a tooth that was previously removed.

Requirements: Allows insurer to validate specific procedures.

Cardinality: 1..*

Type: CodeableReference

Binding: example:tooth

ClaimResponse.addItem.bodySite.subSite

Sub-location

Definition: A region or surface of the bodySite, e.g. limb region or tooth surface(s).

Requirements: Allows insurer to validate specific procedures.

Cardinality: 0..*

Type: CodeableConcept

Binding: example:surface

ClaimResponse.addItem.noteNumber

Applicable note numbers

Definition: The numbers associated with notes below which apply to the adjudication of this item.

Requirements: Provides a condensed manner for associating human readable descriptive explanations for adjudications on the line item.

Cardinality: 0..*

Type: positiveInt

ClaimResponse.addItem.reviewOutcome

Added items adjudication results

Definition: The high-level results of the adjudication if adjudication has been performed.

Cardinality: 0..1

ClaimResponse.addItem.adjudication

Added items adjudication

Definition: The adjudication results.

Cardinality: 0..*

ClaimResponse.addItem.detail

Insurer added line details

Definition: The second-tier service adjudications for payer added services.

Cardinality: 0..*

Type: BackboneElement

ClaimResponse.addItem.detail.traceNumber

Number for tracking

Definition: Trace number for tracking purposes. May be defined at the jurisdiction level or between trading partners.

Requirements: Allows partners to uniquely identify components for tracking.

Cardinality: 0..*

Type: Identifier

ClaimResponse.addItem.detail.revenue

Revenue or cost center code

Definition: The type of revenue or cost center providing the product and/or service.

Requirements: Needed in the processing of institutional claims.

Cardinality: 0..1

Type: CodeableConcept

Binding: example:ex-revenue-center

ClaimResponse.addItem.detail.productOrService

Billing, service, product, or drug code

Requirements: Necessary to state what was provided or done.

Cardinality: 0..1

Type: CodeableConcept

Binding: example:service-uscls

ClaimResponse.addItem.detail.productOrServiceEnd

End of a range of codes

Aliases: End of a range of Drug Code; Bill Code; Service Code

Cardinality: 0..1

Type: CodeableConcept

Binding: example:service-uscls

ClaimResponse.addItem.detail.modifier

Service/Product billing modifiers

Definition: Item typification or modifiers codes to convey additional context for the product or service.

Comments: For example in Oral whether the treatment is cosmetic or associated with TMJ, or for Medical whether the treatment was outside the clinic or outside of office hours.

Requirements: To support inclusion of the item for adjudication or to charge an elevated fee.

Cardinality: 0..*

Type: CodeableConcept

Binding: example:claim-modifiers

Mappings: rim=24.C, 24.D mods

ClaimResponse.addItem.detail.quantity

Count of products or services

Definition: The number of repetitions of a service or product.

Requirements: Required when the product or service code does not convey the quantity provided.

Cardinality: 0..1

Type: Quantity(SimpleQuantity)

Mappings: rim=24.G

ClaimResponse.addItem.detail.unitPrice

Fee, charge or cost per item

Definition: If the item is not a group then this is the fee for the product or service, otherwise this is the total of the fees for the details of the group.

Requirements: The amount charged to the patient by the provider for a single unit.

Cardinality: 0..1

Type: Money

ClaimResponse.addItem.detail.factor

Price scaling factor

Comments: To show a 10% senior's discount, the value entered is: 0.90 (1.00 - 0.10).

Requirements: When discounts are provided to a patient (example: Senior's discount) then this must be documented for adjudication.

Cardinality: 0..1

Type: decimal

ClaimResponse.addItem.detail.tax

Total tax

Definition: The total of taxes applicable for this product or service.

Requirements: Required when taxes are not embedded in the unit price or provided as a separate service.

Cardinality: 0..1

Type: Money

ClaimResponse.addItem.detail.net

Total item cost

Definition: The total amount claimed for the group (if a grouper) or the addItem.detail. Net = unit price * quantity * factor.

Comments: For example, the formula: quantity * unitPrice * factor = net. Quantity and factor are assumed to be 1 if not supplied.

Requirements: Provides the total amount claimed for the group (if a grouper) or the line item.

Cardinality: 0..1

Type: Money

Mappings: rim=24.F

ClaimResponse.addItem.detail.noteNumber

Applicable note numbers

Definition: The numbers associated with notes below which apply to the adjudication of this item.

Requirements: Provides a condensed manner for associating human readable descriptive explanations for adjudications on the line item.

Cardinality: 0..*

Type: positiveInt

ClaimResponse.addItem.detail.reviewOutcome

Added items detail level adjudication results

Definition: The high-level results of the adjudication if adjudication has been performed.

Cardinality: 0..1

ClaimResponse.addItem.detail.adjudication

Added items detail adjudication

Definition: The adjudication results.

Cardinality: 0..*

ClaimResponse.addItem.detail.subDetail

Insurer added line items

Definition: The third-tier service adjudications for payer added services.

Cardinality: 0..*

Type: BackboneElement

ClaimResponse.addItem.detail.subDetail.traceNumber

Number for tracking

Definition: Trace number for tracking purposes. May be defined at the jurisdiction level or between trading partners.

Requirements: Allows partners to uniquely identify components for tracking.

Cardinality: 0..*

Type: Identifier

ClaimResponse.addItem.detail.subDetail.revenue

Revenue or cost center code

Definition: The type of revenue or cost center providing the product and/or service.

Requirements: Needed in the processing of institutional claims.

Cardinality: 0..1

Type: CodeableConcept

Binding: example:ex-revenue-center

ClaimResponse.addItem.detail.subDetail.productOrService

Billing, service, product, or drug code

Requirements: Necessary to state what was provided or done.

Cardinality: 0..1

Type: CodeableConcept

Binding: example:service-uscls

ClaimResponse.addItem.detail.subDetail.productOrServiceEnd

End of a range of codes

Aliases: End of a range of Drug Code; Bill Code; Service Code

Cardinality: 0..1

Type: CodeableConcept

Binding: example:service-uscls

ClaimResponse.addItem.detail.subDetail.modifier

Service/Product billing modifiers

Definition: Item typification or modifiers codes to convey additional context for the product or service.

Comments: For example in Oral whether the treatment is cosmetic or associated with TMJ, or for Medical whether the treatment was outside the clinic or outside of office hours.

Requirements: To support inclusion of the item for adjudication or to charge an elevated fee.

Cardinality: 0..*

Type: CodeableConcept

Binding: example:claim-modifiers

Mappings: rim=24.C, 24.D mods

ClaimResponse.addItem.detail.subDetail.quantity

Count of products or services

Definition: The number of repetitions of a service or product.

Requirements: Required when the product or service code does not convey the quantity provided.

Cardinality: 0..1

Type: Quantity(SimpleQuantity)

Mappings: rim=24.G

ClaimResponse.addItem.detail.subDetail.unitPrice

Fee, charge or cost per item

Definition: If the item is not a group then this is the fee for the product or service, otherwise this is the total of the fees for the details of the group.

Requirements: The amount charged to the patient by the provider for a single unit.

Cardinality: 0..1

Type: Money

ClaimResponse.addItem.detail.subDetail.factor

Price scaling factor

Comments: To show a 10% senior's discount, the value entered is: 0.90 (1.00 - 0.10).

Requirements: When discounts are provided to a patient (example: Senior's discount) then this must be documented for adjudication.

Cardinality: 0..1

Type: decimal

ClaimResponse.addItem.detail.subDetail.tax

Total tax

Definition: The total of taxes applicable for this product or service.

Requirements: Required when taxes are not embedded in the unit price or provided as a separate service.

Cardinality: 0..1

Type: Money

ClaimResponse.addItem.detail.subDetail.net

Total item cost

Definition: The total amount claimed for the addItem.detail.subDetail. Net = unit price * quantity * factor.

Comments: For example, the formula: quantity * unitPrice * factor = net. Quantity and factor are assumed to be 1 if not supplied.

Requirements: Provides the total amount claimed for the group (if a grouper) or the line item.

Cardinality: 0..1

Type: Money

Mappings: rim=24.F

ClaimResponse.addItem.detail.subDetail.noteNumber

Applicable note numbers

Definition: The numbers associated with notes below which apply to the adjudication of this item.

Requirements: Provides a condensed manner for associating human readable descriptive explanations for adjudications on the line item.

Cardinality: 0..*

Type: positiveInt

ClaimResponse.addItem.detail.subDetail.reviewOutcome

Added items subdetail level adjudication results

Definition: The high-level results of the adjudication if adjudication has been performed.

Cardinality: 0..1

ClaimResponse.addItem.detail.subDetail.adjudication

Added items subdetail adjudication

Definition: The adjudication results.

Cardinality: 0..*

ClaimResponse.adjudication

Header-level adjudication

Definition: The adjudication results which are presented at the header level rather than at the line-item or add-item levels.

Requirements: Some insurers will receive line-items but provide the adjudication only at a summary or header-level.

Cardinality: 0..*

ClaimResponse.total

Adjudication totals

Definition: Categorized monetary totals for the adjudication.

Comments: Totals for amounts submitted, co-pays, benefits payable etc.

Requirements: To provide the requestor with financial totals by category for the adjudication.

Cardinality: 0..*

Type: BackboneElement

Summary: true

ClaimResponse.total.category

Type of adjudication information

Definition: A code to indicate the information type of this adjudication record. Information types may include: the value submitted, maximum values or percentages allowed or payable under the plan, amounts that the patient is responsible for in aggregate or pertaining to this item, amounts paid by other coverages, and the benefit payable for this item.

Comments: For example codes indicating: Co-Pay, deductible, eligible, benefit, tax, etc.

Requirements: Needed to convey the type of total provided.

Cardinality: 1..1

Type: CodeableConcept

Binding: example:adjudication

Summary: true

ClaimResponse.total.amount

Financial total for the category

Definition: Monetary total amount associated with the category.

Requirements: Needed to convey the total monetary amount.

Cardinality: 1..1

Type: Money

Summary: true

ClaimResponse.payment

Payment Details

Definition: Payment details for the adjudication of the claim.

Requirements: Needed to convey references to the financial instrument that has been used if payment has been made.

Cardinality: 0..1

Type: BackboneElement

ClaimResponse.payment.type

Partial or complete payment

Definition: Whether this represents partial or complete payment of the benefits payable.

Requirements: To advise the requestor when the insurer believes all payments to have been completed.

Cardinality: 1..1

Type: CodeableConcept

Binding: preferred:ex-paymenttype

ClaimResponse.payment.adjustment

Payment adjustment for non-claim issues

Definition: Total amount of all adjustments to this payment included in this transaction which are not related to this claim's adjudication.

Comments: Insurers will deduct amounts owing from the provider (adjustment), such as a prior overpayment, from the amount owing to the provider (benefits payable) when payment is made to the provider.

Requirements: To advise the requestor of adjustments applied to the payment.

Cardinality: 0..1

Type: Money

ClaimResponse.payment.adjustmentReason

Explanation for the adjustment

Definition: Reason for the payment adjustment.

Requirements: Needed to clarify the monetary adjustment.

Cardinality: 0..1

Type: CodeableConcept

Binding: preferred:payment-adjustment-reason

ClaimResponse.payment.date

Expected date of payment

Definition: Estimated date the payment will be issued or the actual issue date of payment.

Requirements: To advise the payee when payment can be expected.

Cardinality: 0..1

Type: date

ClaimResponse.payment.amount

Payable amount after adjustment

Definition: Benefits payable less any payment adjustment.

Requirements: Needed to provide the actual payment amount.

Cardinality: 1..1

Type: Money

ClaimResponse.payment.identifier

Business identifier for the payment

Definition: Issuer's unique identifier for the payment instrument.

Comments: For example: EFT number or check number.

Requirements: Enable the receiver to reconcile when payment received.

Cardinality: 0..1

Type: Identifier

ClaimResponse.fundsReserve

Funds reserved status

Definition: A code, used only on a response to a preauthorization, to indicate whether the benefits payable have been reserved and for whom.

Comments: Fund would be release by a future claim quoting the preAuthRef of this response. Examples of values include: provider, patient, none.

Requirements: Needed to advise the submitting provider on whether the request for reservation of funds has been honored.

Cardinality: 0..1

Type: CodeableConcept

Binding: preferred:fundsreserve

ClaimResponse.formCode

Printed form identifier

Definition: A code for the form to be used for printing the content.

Comments: May be needed to identify specific jurisdictional forms.

Requirements: Needed to specify the specific form used for producing output for this response.

Cardinality: 0..1

Type: CodeableConcept

Binding: example:forms

ClaimResponse.form

Printed reference or actual form

Definition: The actual form, by reference or inclusion, for printing the content or an EOB.

Comments: Needed to permit insurers to include the actual form.

Requirements: Needed to include the specific form used for producing output for this response.

Cardinality: 0..1

Type: Attachment

ClaimResponse.processNote

Note concerning adjudication

Definition: A note that describes or explains adjudication results in a human readable form.

Requirements: Provides the insurer specific textual explanations associated with the processing.

Cardinality: 0..*

Type: BackboneElement

ClaimResponse.processNote.class

Business kind of note

Definition: A code to indicate the business purpose of the note.

Requirements: Process Notes may encompass a significant number of kinds of notes. These could be disclaimers (particularly useful for predetermination), a statement about adjudication, a conditional statement, or others.

Cardinality: 0..1

Type: CodeableConcept

Binding: example

ClaimResponse.processNote.number

Note instance identifier

Definition: A number to uniquely identify a note entry.

Requirements: Necessary to provide a mechanism to link from adjudications.

Cardinality: 0..1

Type: positiveInt

ClaimResponse.processNote.type

Note purpose

Definition: The business purpose of the note text.

Requirements: To convey the expectation for when the text is used.

Cardinality: 0..1

Type: CodeableConcept

Binding: extensible:note-type

ClaimResponse.processNote.text

Note explanatory text

Definition: The explanation or description associated with the processing.

Requirements: Required to provide human readable explanation.

Cardinality: 1..1

Type: markdown

ClaimResponse.processNote.language

Language of the text

Definition: A code to define the language used in the text of the note.

Comments: Only required if the language is different from the resource language.

Requirements: Note text may vary from the resource defined language.

Cardinality: 0..1

Type: CodeableConcept

Binding: required:all-languages

ClaimResponse.communicationRequest

Request for additional information

Definition: Request for additional supporting or authorizing information.

Comments: For example: professional reports, documents, images, clinical resources, or accident reports.

Requirements: Need to communicate insurer request for additional information required to support the adjudication.

Cardinality: 0..*

Type: Reference(CommunicationRequest)

ClaimResponse.insurance

Patient insurance information

Definition: Financial instruments for reimbursement for the health care products and services specified on the claim.

Comments: All insurance coverages for the patient which may be applicable for reimbursement, of the products and services listed in the claim, are typically provided in the claim to allow insurers to confirm the ordering of the insurance coverages relative to local 'coordination of benefit' rules. One coverage (and only one) with 'focal=true' is to be used in the adjudication of this claim. Coverages appearing before the focal Coverage in the list, and where 'subrogation=false', should provide a reference to the ClaimResponse containing the adjudication results of the prior claim.

Requirements: At least one insurer is required for a claim to be a claim.

Cardinality: 0..*

Type: BackboneElement

Mappings: rim=Coverage

ClaimResponse.insurance.sequence

Insurance instance identifier

Definition: A number to uniquely identify insurance entries and provide a sequence of coverages to convey coordination of benefit order.

Requirements: To maintain order of the coverages.

Cardinality: 1..1

Type: positiveInt

ClaimResponse.insurance.focal

Coverage to be used for adjudication

Definition: A flag to indicate that this Coverage is to be used for adjudication of this claim when set to true.

Comments: A patient may (will) have multiple insurance policies which provide reimbursement for healthcare services and products. For example a person may also be covered by their spouse's policy and both appear in the list (and may be from the same insurer). This flag will be set to true for only one of the listed policies and that policy will be used for adjudicating this claim. Other claims would be created to request adjudication against the other listed policies.

Requirements: To identify which coverage in the list is being used to adjudicate this claim.

Cardinality: 1..1

Type: boolean

ClaimResponse.insurance.coverage

Insurance information

Definition: Reference to the insurance card level information contained in the Coverage resource. The coverage issuing insurer will use these details to locate the patient's actual coverage within the insurer's information system.

Requirements: Required to allow the adjudicator to locate the correct policy and history within their information system.

Cardinality: 1..1

Type: Reference(Coverage)

ClaimResponse.insurance.businessArrangement

Additional provider contract number

Definition: A business agreement number established between the provider and the insurer for special business processing purposes.

Requirements: Providers may have multiple business arrangements with a given insurer and must supply the specific contract number for adjudication.

Cardinality: 0..1

Type: string

ClaimResponse.insurance.claimResponse

Adjudication results

Definition: The result of the adjudication of the line items for the Coverage specified in this insurance.

Comments: Must not be specified when 'focal=true' for this insurance.

Requirements: An insurer need the adjudication results from prior insurers to determine the outstanding balance remaining by item for the items in the curent claim.

Cardinality: 0..1

Type: Reference(ClaimResponse)

ClaimResponse.error

Processing errors

Definition: Errors encountered during the processing of the adjudication.

Comments: If the request contains errors then an error element should be provided and no adjudication related sections (item, addItem, or payment) should be present.

Requirements: Need to communicate processing issues to the requestor.

Cardinality: 0..*

Type: BackboneElement

ClaimResponse.error.itemSequence

Item sequence number

Definition: The sequence number of the line item submitted which contains the error. This value is omitted when the error occurs outside of the item structure.

Requirements: Provides references to the claim items.

Cardinality: 0..1

Type: positiveInt

ClaimResponse.error.detailSequence

Detail sequence number

Definition: The sequence number of the detail within the line item submitted which contains the error. This value is omitted when the error occurs outside of the item structure.

Requirements: Provides references to the claim details within the claim item.

Cardinality: 0..1

Type: positiveInt

ClaimResponse.error.subDetailSequence

Subdetail sequence number

Definition: The sequence number of the sub-detail within the detail within the line item submitted which contains the error. This value is omitted when the error occurs outside of the item structure.

Requirements: Provides references to the claim sub-details within the claim detail.

Cardinality: 0..1

Type: positiveInt

ClaimResponse.error.code

Error code detailing processing issues

Definition: An error code, from a specified code system, which details why the claim could not be adjudicated.

Requirements: Required to convey processing errors.

Cardinality: 1..1

Type: CodeableConcept

Binding: example:adjudication-error

Summary: true

ClaimResponse.error.expression

FHIRPath of element(s) related to issue

Definition: A simple subset of FHIRPath limited to element names, repetition indicators and the default child accessor that identifies one of the elements in the resource that caused this issue to be raised.

Comments: The root of the FHIRPath is the resource or bundle that generated OperationOutcome. Each FHIRPath SHALL resolve to a single node.

Requirements: Allows systems to highlight or otherwise guide users to elements implicated in issues to allow them to be fixed more easily.

Cardinality: 0..*

Type: string

Summary: true