ClaimResponse | Medplum
This resource provides the adjudication details from the processing of a Claim resource.
Elements
| Name | Required | Type | Description |
|---|---|---|---|
| identifier | Identifier[] | Business Identifier for a claim response | |
| Details | |||
| A unique identifier assigned to this claim response. | |||
| status | ✓ | code | active |
| Details | |||
| The status of the resource instance. | |||
| This element is labeled as a modifier because the status contains codes that mark the resource as not currently valid. | |||
| type | ✓ | CodeableConcept | More granular claim type |
| Details | |||
| A finer grained suite of claim type codes which may convey additional information such as Inpatient vs Outpatient and/or a specialty service. | |||
| This may contain the local bill type codes, for example the US UB-04 bill type code or the CMS bill type. | |||
| subType | CodeableConcept | More granular claim type | |
| Details | |||
| A finer grained suite of claim type codes which may convey additional information such as Inpatient vs Outpatient and/or a specialty service. | |||
| This may contain the local bill type codes, for example the US UB-04 bill type code or the CMS bill type. | |||
| use | ✓ | code | claim |
| Details | |||
| A code to indicate whether the nature of the request is: to request adjudication of products and services previously rendered; or requesting authorization and adjudication for provision in the future; or requesting the non-binding adjudication of the listed products and services which could be provided in the future. | |||
| patient | ✓ | Reference< Patient > | The recipient of the products and services |
| Details | |||
| 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. | |||
| created | ✓ | dateTime | Response creation date |
| Details | |||
| The date this resource was created. | |||
| insurer | ✓ | Reference< Organization > | Party responsible for reimbursement |
| Details | |||
| The party responsible for authorization, adjudication and reimbursement. | |||
| requestor | Reference< Practitioner |
PractitionerRole |
|
| Details | |||
| The provider which is responsible for the claim, predetermination or preauthorization. | |||
| Typically this field would be 1..1 where this party is responsible for the claim but not necessarily professionally responsible for the provision of the individual products and services listed below. | |||
| request | Reference< Claim > | Id of resource triggering adjudication | |
| Details | |||
| Original request resource reference. | |||
| outcome | ✓ | code | queued |
| Details | |||
| The outcome of the claim, predetermination, or preauthorization processing. | |||
| The resource may be used to indicate that: the request has been held (queued) for processing; that it has been processed and errors found (error); that no errors were found and that some of the adjudication has been undertaken (partial) or that all of the adjudication has been undertaken (complete). | |||
| disposition | string | Disposition Message | |
| Details | |||
| A human readable description of the status of the adjudication. | |||
| preAuthRef | string | Preauthorization reference | |
| Details | |||
| Reference from the Insurer which is used in later communications which refers to this adjudication. | |||
| This value is only present on preauthorization adjudications. | |||
| preAuthPeriod | Period | Preauthorization reference effective period | |
| Details | |||
| The time frame during which this authorization is effective. | |||
| payeeType | CodeableConcept | Party to be paid any benefits payable | |
| Details | |||
| Type of Party to be reimbursed: subscriber, provider, other. | |||
| item | ClaimResponseItem[] | Adjudication for claim line items | |
| Details | |||
| 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. | |||
| id | string | Unique id for inter-element referencing | |
| Details | |||
| Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. | |||
| extension | Extension[] | Additional content defined by implementations | |
| Details | |||
| May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. | |||
| There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. | |||
| modifierExtension | Extension[] | Extensions that cannot be ignored even if unrecognized | |
| Details | |||
| May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. | |||
| Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). | |||
| There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. | |||
| itemSequence | ✓ | positiveInt | Claim item instance identifier |
| Details | |||
| A number to uniquely reference the claim item entries. | |||
| noteNumber | positiveInt[] | Applicable note numbers | |
| Details | |||
| The numbers associated with notes below which apply to the adjudication of this item. | |||
| adjudication | ✓ | ClaimResponseItemAdjudication[] | Adjudication details |
| Details | |||
| 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. | |||
| id | string | Unique id for inter-element referencing | |
| Details | |||
| Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. | |||
| extension | Extension[] | Additional content defined by implementations | |
| Details | |||
| May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. | |||
| There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. | |||
| modifierExtension | Extension[] | Extensions that cannot be ignored even if unrecognized | |
| Details | |||
| May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. | |||
| Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). | |||
| There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. |
Additional Information
Additional information regarding electronic claims content and usage may be found at:
- Financial Resource Status Lifecycle: how .status is used in the financial resources.
- Secondary Use of Resources: how resources such as Claim, ClaimResponse and ExplanationOfBenefit may be used for reporting and data exchange for analytics, not just for eClaims exchange between providers and payors.
- Subrogation: how eClaims may handle patient insurance coverages when another insurer rather than the provider will settle the claim and potentially recover costs against specified coverages.
- Coordination of Benefit: how eClaims may handle multiple patient insurance coverages.
- RealTime Exchange and Obtaining Deferred Responses: ClaimResponses may be obtained using Polling or FHIR REST (SEARCH).
- Attachments and Supporting Information: how eClaims may handle the provision of supporting information, whether provided by content or reference, within the eClaim resource when submitted to the payor or later in a resource which refers to the subject eClaim resource. This also includes how payors may request additional supporting information from providers.