ClaimResponse $status-response

An asynchronous response to the $status operation on Claim. Reports various statuses on 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 the claim status response 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
id
string

A response detailing the status of each line item.

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, [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

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.

reason
object

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

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.

adjudication
[object]

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

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.

reason
object

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

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.

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/$status-response
Open dropdown

A claim for one patient receiving inpatient services for blood work and an EKG. Attending Provider was Pat Granite, and Referring provider was Joan Fishman.

Response Fields and Example
resourceType
required, string

Identifies the type of the resource

Value: OperationOutcome
issue
required, [object]

A structured respresentation of the error that occurred

severity
required, string

Generally error or fatal

Possible Values: fatal, error, warning, information
code
required, string

A FHIR category code that describes the general type of issue. See http://hl7.org/fhir/ValueSet/issue-type for details

id
string

If the error occurs in the RedoxEngine, this corresponds to an Error record in the organization.

details
object

Additional details about the error. This may be a text description of the error or a system code that identifies the error.

coding
[object]

A more granular FHIR code for the specific error. Typically from http://hl7.org/fhir/ValueSet/operation-outcome

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-readable interpretation of the issue code

diagnostics
string

Additional diagnostic information about the issue.