ClaimResponse $payment

An asynchronous payment/advice transaction typically from a payer. Contains information about payments made, and any adjustments, denials, or additional information on a per-item basis.

Request Fields and Example
resourceType
required, string

Identifies the type of the resource

Value: Bundle
type
required, string

Indicates the purpose of this bundle - how it is intended to be used.

Value: collection
entry
required, [ClaimResponse, Patient, Coverage, Location, Practitioner, RelatedPerson, Other]

An array of FHIR resources. At a minimum, a ClaimResponse should include the following entries:

  • ClaimResponse - the most important part of the request - contains references to all other resources, details adjudication at the appropriate levels.
  • Patient - the patient the claim is for.
  • Organization - at least one resource representing the party responsible for making the claim. Additional organization resources may carry information such as pharmacy, payor, or policy holder.
  • Practitioner - for professional claims the provider submitting the claim
  • Coverage - the patient's insurance
Any of:
resource
required, object

The Resource for the entry. The purpose/meaning of the resource is determined by the Bundle.type.

resourceType
required, string

Identifies the type of the resource

Value: ClaimResponse
status
required, string

The status of the resource instance.

Value: active
type
required, object

Type of claim. Example Codes The recommended system is http://terminology.hl7.org/CodeSystem/claim-type. Typical values include

  • pharmacy - Pharmacy claims for goods and services
  • professional - Typically outpatient claims such as Psychological, Chiropractor, rehabilitative, consulting
  • institutional - Hospital, clinic and other inpatient claims
coding
[object]

A reference to a code defined by a terminology system.

system
string

The identification of the code system that defines the meaning of the symbol in the code.

code
string

A symbol in syntax defined by the system. The symbol may be a predefined code or an expression in a syntax defined by the coding system (e.g. post-coordination).

text
string

A human language representation of the concept as seen/selected/uttered by the user who entered the data and/or which represents the intended meaning of the user.

use
required, string

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.

Value: claim
patient
required, object

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.

Must be a resource of type Patient.

reference
string

A reference to a Patient resource

created
required, string

The date this resource was created.

insurer
required, object

The party responsible for authorization, adjudication and reimbursement.

Must be a resource of type Organization.

reference
string

A reference to another resource. This is typically either a relative reference which includes the resource type and ID, or an internal reference which starts with # and refers to a contained resource.

outcome
required, string

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

Possible Values: queued, complete, error, partial
total
required, [adjudicationamounttype, Other]

Categorized monetary totals for the adjudication.

Any of:

Total adjudication type and amount

category
required, object

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.

coding
[object]

A reference to a code defined by a terminology system.

system
string

The identification of the code system that defines the meaning of the symbol in the code.

code
string

A symbol in syntax defined by the system. The symbol may be a predefined code or an expression in a syntax defined by the coding system (e.g. post-coordination).

text
string

A human language representation of the concept as seen/selected/uttered by the user who entered the data and/or which represents the intended meaning of the user.

amount
required, object

Monetary total amount associated with the category.

value
number

Numerical value (with implicit precision).

currency
string

ISO 4217 Currency Code (e.g. USD for US Dollar)

id
string

A unique identifier for the ClaimResponse that can be used to communicate back to the Payer for a resubmission.

requestor
object

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

Must reference one of the following types of resources:

  • Practitioner
  • Organization
reference
string

A reference to a Practitioner or Organization resource, depending on the setting.

item
[object]

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.

itemSequence
required, number

A number to uniquely reference the claim item entries.

adjudication
required, [adjudicationamounttype, denialreason, allowedunits, Other]

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.

Any of:

Line level adjudication type and amount

category
required, object

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.

coding
[object]

A reference to a code defined by a terminology system.

system
string

The identification of the code system that defines the meaning of the symbol in the code.

code
string

A symbol in syntax defined by the system. The symbol may be a predefined code or an expression in a syntax defined by the coding system (e.g. post-coordination).

text
string

A human language representation of the concept as seen/selected/uttered by the user who entered the data and/or which represents the intended meaning of the user.

amount
required, object

Monetary amount associated with the category.

value
number

Numerical value (with implicit precision).

currency
string

ISO 4217 Currency Code (e.g. USD for US Dollar)

id
string

A unique id for the line item. This can be used on subsequent status checks to get-line-level status information.

adjudication
[adjudicationamounttype, denialreason, Other]

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

Any of:

Line level adjudication type and amount

category
required, object

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.

coding
[object]

A reference to a code defined by a terminology system.

system
string

The identification of the code system that defines the meaning of the symbol in the code.

code
string

A symbol in syntax defined by the system. The symbol may be a predefined code or an expression in a syntax defined by the coding system (e.g. post-coordination).

text
string

A human language representation of the concept as seen/selected/uttered by the user who entered the data and/or which represents the intended meaning of the user.

amount
required, object

Monetary amount associated with the category.

value
number

Numerical value (with implicit precision).

currency
string

ISO 4217 Currency Code (e.g. USD for US Dollar)

payment
object

Payment details for the adjudication of the claim.

type
required, object

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

coding
[object]

A reference to a code defined by a terminology system.

system
string

The identification of the code system that defines the meaning of the symbol in the code.

code
string

A symbol in syntax defined by the system. The symbol may be a predefined code or an expression in a syntax defined by the coding system (e.g. post-coordination).

text
string

A human language representation of the concept as seen/selected/uttered by the user who entered the data and/or which represents the intended meaning of the user.

amount
required, object

Benefits payable less any payment adjustment.

value
number

Numerical value (with implicit precision).

currency
string

ISO 4217 Currency Code (e.g. USD for US Dollar)

identifier
object

Issuer's unique identifier for the payment instrument.

type
object

A coded type for the identifier that can be used to determine which identifier to use for a specific purpose.

coding
[object]

A reference to a code defined by a terminology system.

system
string

The identification of the code system that defines the meaning of the symbol in the code.

code
string

A symbol in syntax defined by the system. The symbol may be a predefined code or an expression in a syntax defined by the coding system (e.g. post-coordination).

text
string

A human language representation of the concept as seen/selected/uttered by the user who entered the data and/or which represents the intended meaning of the user.

system
string

Establishes the namespace for the value - that is, a URL that describes a set values that are unique.

value
string

The portion of the identifier typically relevant to the user and which is unique within the context of the system.

insurance
[object]

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

sequence
required, number

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

focal
required, boolean

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

coverage
required, object

Reference to Coverage resource for patient.

Must be a resource of type Coverage.

reference
string

A reference to another resource. This is typically either a relative reference which includes the resource type and ID, or an internal reference which starts with # and refers to a contained resource.

businessArrangement
string

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

post/ClaimResponse/$payment
ProfessionalPaymentBundle

A partially paid claim .