---
type: "resource-definitions"
title: "ClaimResponse Definitions"
resource: "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](/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](/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](/code)
**Binding:** required:[fm-status](/valueset-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](/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](/CodeableConcept)
**Binding:** extensible:[claim-type](/valueset-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](/CodeableConcept)
**Binding:** example:[claim-subtype](/valueset-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](/code)
**Binding:** required:[claim-use](/valueset-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](/Patient), [Group](/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](/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](/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](/Practitioner), [PractitionerRole](/PractitionerRole), [Organization](/Organization))
**Mappings:** w5=FiveWs.source
## ClaimResponse.request
Id of resource triggering adjudication
**Definition:** Original request resource reference.
**Cardinality:** 0..1
**Type:** Reference([Claim](/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](/code)
**Binding:** required:[claim-outcome](/valueset-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](/CodeableConcept)
**Binding:** preferred:[claim-decision](/valueset-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](/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](/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](/Period)
## ClaimResponse.event
Event information
**Definition:** Information code for an event with a corresponding date or period.
**Cardinality:** 0..*
**Type:** [BackboneElement](/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](/CodeableConcept)
**Binding:** example:[datestype](/valueset-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](/dateTime), [Period](/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](/CodeableConcept)
**Binding:** example:[payeetype](/valueset-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](/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](/CodeableConcept)
**Binding:** example:[ex-diagnosisrelatedgroup](/valueset-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](/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](/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](/CodeableConcept)
**Binding:** preferred:[claim-informationcategory](/valueset-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](/CodeableConcept)
**Binding:** example:[claim-exception](/valueset-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](/dateTime), [Period](/Period), [Timing](/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](/CodeableConcept)
**Binding:** example:[missing-tooth-reason](/valueset-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](/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](/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](/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](/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](/positiveInt)
## ClaimResponse.item.reviewOutcome
Adjudication results
**Definition:** The high-level results of the adjudication if adjudication has been performed.
**Cardinality:** 0..1
**Type:** [BackboneElement](/BackboneElement)
## ClaimResponse.item.reviewOutcome.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](/CodeableConcept)
**Binding:** preferred:[claim-decision](/valueset-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](/CodeableConcept)
**Binding:** example:[claim-decision-reason](/valueset-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](/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](/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](/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](/CodeableConcept)
**Binding:** preferred:[adjudication](/valueset-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](/CodeableConcept)
**Binding:** example:[adjudication-reason](/valueset-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](/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](/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](/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](/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](/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](/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](/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](/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](/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](/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](/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](/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](/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](/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](/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](/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](/Patient), [Group](/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](/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](/Practitioner), [PractitionerRole](/PractitionerRole), [Organization](/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](/CodeableConcept)
**Binding:** example:[ex-revenue-center](/valueset-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](/CodeableConcept)
**Binding:** example:[ex-benefitcategory](/valueset-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](/CodeableConcept)
**Binding:** example:[service-uscls](/valueset-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](/CodeableConcept)
**Binding:** example:[service-uscls](/valueset-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](/DeviceRequest), [MedicationRequest](/MedicationRequest), [NutritionOrder](/NutritionOrder), [ServiceRequest](/ServiceRequest), [VisionPrescription](/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](/CodeableConcept)
**Binding:** example:[claim-modifiers](/valueset-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](/CodeableConcept)
**Binding:** example:[ex-program-code](/valueset-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](/date), [Period](/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](/CodeableConcept), [Address](/Address), Reference([Location](/Location))
**Binding:** example:[service-place](/valueset-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](/Quantity)([SimpleQuantity](/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](/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](/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](/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](/Money)
**Mappings:** rim=24.F
## ClaimResponse.addItem.bodySite
Anatomical location
**Definition:** Physical location where the service is performed or applies.
**Cardinality:** 0..*
**Type:** [BackboneElement](/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](/CodeableReference)
**Binding:** example:[tooth](/valueset-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](/CodeableConcept)
**Binding:** example:[surface](/valueset-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](/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](/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](/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](/CodeableConcept)
**Binding:** example:[ex-revenue-center](/valueset-ex-revenue-center)
## ClaimResponse.addItem.detail.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](/CodeableConcept)
**Binding:** example:[service-uscls](/valueset-service-uscls)
## ClaimResponse.addItem.detail.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](/CodeableConcept)
**Binding:** example:[service-uscls](/valueset-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](/CodeableConcept)
**Binding:** example:[claim-modifiers](/valueset-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](/Quantity)([SimpleQuantity](/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](/Money)
## ClaimResponse.addItem.detail.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](/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](/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](/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](/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](/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](/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](/CodeableConcept)
**Binding:** example:[ex-revenue-center](/valueset-ex-revenue-center)
## ClaimResponse.addItem.detail.subDetail.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](/CodeableConcept)
**Binding:** example:[service-uscls](/valueset-service-uscls)
## ClaimResponse.addItem.detail.subDetail.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](/CodeableConcept)
**Binding:** example:[service-uscls](/valueset-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](/CodeableConcept)
**Binding:** example:[claim-modifiers](/valueset-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](/Quantity)([SimpleQuantity](/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](/Money)
## ClaimResponse.addItem.detail.subDetail.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](/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](/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](/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](/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](/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](/CodeableConcept)
**Binding:** example:[adjudication](/valueset-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](/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](/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](/CodeableConcept)
**Binding:** preferred:[ex-paymenttype](/valueset-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](/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](/CodeableConcept)
**Binding:** preferred:[payment-adjustment-reason](/valueset-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](/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](/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](/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](/CodeableConcept)
**Binding:** preferred:[fundsreserve](/valueset-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](/CodeableConcept)
**Binding:** example:[forms](/valueset-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](/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](/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](/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](/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](/CodeableConcept)
**Binding:** extensible:[note-type](/valueset-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](/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](/CodeableConcept)
**Binding:** required:[all-languages](/valueset-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](/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](/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](/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](/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](/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](/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))
## 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](/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](/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](/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](/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](/CodeableConcept)
**Binding:** example:[adjudication-error](/valueset-adjudication-error)
**Summary:** true
## ClaimResponse.error.expression
FHIRPath of element(s) related to issue
**Definition:** A [simple subset of FHIRPath](fhirpath.html#simple) 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](/string)
**Summary:** true