ClaimResponse $respond

Send an asynchronous response to a preauthorization claim. The request payload is identical to the response payload of a Claim/$submit operation.

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
timestamp
required, string

The date/time that the bundle was assembled - i.e. when the resources were placed in the bundle.

entry
required, [ClaimResponse, Patient, Coverage, Organization, PractitionerRole, Practitioner, RelatedPerson, Claim, Other]

An array of FHIR resources including the following:

  • ClaimResponse - the primary response resource
  • Patient - the patient the claim response is about
  • 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.
  • Coverage - the patient's insurance

The ClaimResponse is the only resource that must be present in the bundle. It references several other of the above resources which should already be known to the requesting system.

However, some workflows may not always persist the information, so it is best practice for the responding system to preserve and re-include all referenced resources in the Claim Response bundle.

Any of:

An entry in a bundle resource - will either contain a resource or information about a resource (transactions and history only).

resource
required, object

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

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

For prescriptions, typically code='pharmacy' and system='http://terminology.hl7.org/CodeSystem/claim-type'

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: preauthorization
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 an Organization resource

outcome
required, string

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

queued | complete | error | partial

Possible Values: queued, complete, error, partial
requestor
object

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

Must be a resource of type Organization.

reference
string

A reference to an Organization resource

request
object

A reference to the Claim resource triggering adjudication. This can be either the same identifier as the original Claim.identifier or else reference can point to the Claim.id value. When sending only the reference, it is helpful to also include the original Claim resource in the request.

Must be a resource of type Claim.

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.

identifier
object

An identifier for the target resource. This is used when there is no way to reference the other resource directly, either because the entity it represents is not available through a FHIR server, or because there is no way for the author of the resource to convert a known identifier to an actual location. There is no requirement that a Reference.identifier point to something that is actually exposed as a FHIR instance, but it SHALL point to a business concept that would be expected to be exposed as a FHIR instance, and that instance would need to be of a FHIR resource type allowed by the reference.

extension
[Boolean, String, CodeableConcept, Coding, HumanName, Reference]

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.

One of:
url
required, string

Source of the definition for the extension code - a logical name or a URL.

valueBoolean
boolean

A single value for the extension.

use
string

The purpose of this identifier.

Possible Values: usual, official, temp, secondary, old (If known)
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.

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, [object]

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.

category
required, object

Type of adjudication information. Example Codes

coding
required, [object]

A reference to a code defined by a terminology system.

system
required, string

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

Value: http://terminology.hl7.org/CodeSystem/adjudication
code
required, 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).

Value: submitted
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.

extension
[reviewAction, Other]

An Extension

Any of:

The details of the review action that is necessary for the authorization.

See http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-reviewAction for more information

url
required, string

Source of the definition for the extension code - a logical name or a URL.

Value: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-reviewAction
extension
[code, number, Other]

Details of the review action that is necessary for the authorization, carried in sub-extension properties.

Any of:

The code describing the result of the review.

See http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-reviewActionCode for more information

url
required, string

Source of the definition for the extension code - a logical name or a URL.

Value: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-reviewActionCode
valueCodeableConcept
object

Code indicating the type of action, from the X12 306 code set.

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
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)

value
number

Non-monetary value. Used, for example, when the adjudication is a percentage.

extension
[itemTraceNumber, preAuthIssueDate, preAuthPeriod, administrationReferenceNumber, authorizedItemDetail, communicatedDiagnosis, Other]

Additional information about the item

Any of:

Uniquely identifies this claim item. (2000F-TRN)

See http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemTraceNumber for more information

url
required, string

Source of the definition for the extension code - a logical name or a URL.

Value: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemTraceNumber
valueIdentifier
object

Uniquely identifies this claim item

value
string

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

processNote
[object]

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

text
required, string

The explanation or description associated with the processing.

post/ClaimResponse/$respond
Open dropdown

A claim response demonstrating inclusion of the original resources associated with the claim request. Many of these resources are redundant and need not actually be sent with a response bundle.