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FHIR® API
FHIR® resources
ClaimResponse
$payment

ClaimResponse $payment

post/ClaimResponse/$payment
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This resource contains claim statuses, payments, or responses. As a payer, you can use this resource to asynchronously respond to claims that were previously submitted by healthcare organizations. 

You can send payment, status updates, or other related asynchronous claim responses with this resource type.

$payment

Send payment details, including authorizations, adjustments, denials, or additional information for each line item of the claim.

This is an asynchronous operation.

Request parameters and payload

cURL request example

bash
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curl 'https://api.redoxengine.com/fhir/R4/{destinationSlug}/{environmentFlag}/ClaimResponse/$payment' \
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--request POST \
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--header 'Authorization: Bearer $API_TOKEN' \
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--header 'Content-Type: application/fhir+json' \
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--data '{
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  "resourceType": "Bundle",
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  "id": "ProfessionalPaymentBundle",
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  "type": "collection",
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  "identifier": {
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    "system": "urn:ietf:rfc:3986",
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    "value": "urn:uuid:59f129cf-2eca-4965-88f2-452558af1934"
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  },
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  "timestamp": "2022-07-02T19:09:02.452Z",
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  "entry": [
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    {
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      "resource": {
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        "resourceType": "ClaimResponse",
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        "id": "PaymentProfessional",
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        "meta": {
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          "lastUpdated": "2022-12-12T09:14:11+00:00"
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        },
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        "status": "active",
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        "use": "claim",
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        "language": "en-US",
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        "identifier": [
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          {
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            "value": "urn:uuid:e69ba9b3-407a-4da6-bde2-d1b48792fadf",
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            "system": "https://www.insurance.com/fhir"
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          }
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        ],
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        "type": {
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          "coding": [
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            {
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              "code": "professional",
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              "system": "http://terminology.hl7.org/CodeSystem/claim-type"
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            }
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          ],
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          "text": "Professional"
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        },
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        "created": "2022-07-02T00:00:00+00:00",
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        "insurer": {
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          "reference": "Organization/RedoxInsurerOrganizationExample"
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        },
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        "patient": {
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          "reference": "Patient/RedoxPABeneficiaryExample"
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        },
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        "requestor": {
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          "reference": "Practitioner/RedoxPractitionerExampleJoan"
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        },
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        "outcome": "partial",
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        "total": [
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          {
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            "category": {
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              "coding": [
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                {
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                  "code": "paidtoprovider",
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                  "system": "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication"
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                }
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              ],
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              "text": "Payment Amount"
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            },
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            "amount": {
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              "value": 520,
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              "currency": "USD"
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            }
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          },
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          {
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            "category": {
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              "coding": [
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                {
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                  "code": "submitted",
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                  "system": "http://terminology.hl7.org/CodeSystem/adjudication"
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                }
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              ],
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              "text": "Submitted Amount"
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            },
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            "amount": {
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              "value": 2550,
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              "currency": "USD"
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            }
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          },
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          {
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            "category": {
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              "coding": [
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                {
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                  "code": "paidbypatient",
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                  "system": "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication"
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                }
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              ],
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              "text": "Patient Pay Amount"
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            },
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            "amount": {
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              "value": 30,
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              "currency": "USD"
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            }
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          }
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        ],
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        "item": [
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          {
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            "itemSequence": 1,
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            "adjudication": [
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              {
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                "category": {
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                  "coding": [
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                    {
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                      "code": "submitted",
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                      "system": "http://terminology.hl7.org/CodeSystem/adjudication"
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                    }
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                  ]
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                },
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                "amount": {
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                  "value": 1000,
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                  "currency": "USD"
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                }
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              }
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            ]
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          }
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        ],
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        "insurance": [
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          {
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            "sequence": 1,
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            "focal": true,
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            "coverage": {
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              "reference": "Coverage/RedoxPACoverageExample"
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            }
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          }
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        ]
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      }
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    },
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    {
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      "resource": {
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        "resourceType": "Patient",
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        "id": "RedoxPABeneficiaryExample",
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        "identifier": [
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          {
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            "system": "urn:redox:MRN",
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            "value": "M23462346"
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          }
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        ],
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        "name": [
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          {
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            "given": [
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              "Timothy",
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              "Paul"
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            ],
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            "family": "Bixby"
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          }
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        ],
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        "gender": "male",
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        "birthDate": "2008-01-06"
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      }
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    },
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    {
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      "resource": {
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        "resourceType": "Coverage",
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        "id": "RedoxPACoverageExample",
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        "class": [
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          {
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            "type": {
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              "coding": [
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                {
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                  "code": "group",
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                  "system": "http://terminology.hl7.org/CodeSystem/coverage-class"
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                }
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              ]
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            },
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            "value": "GRP2245"
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          }
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        ],
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        "status": "active",
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        "beneficiary": {
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          "reference": "Patient/RedoxPABeneficiaryExample"
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        },
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        "payor": [
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          {
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            "reference": "Organization/RedoxPAInsurerOrganizationExample"
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          }
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        ],
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        "subscriber": {
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          "reference": "Patient/RedoxPABeneficiaryExample"
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        },
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        "subscriberId": "T75644"
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      }
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    },
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    {
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      "resource": {
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        "resourceType": "Organization",
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        "id": "RedoxPAInsurerOrganizationExample",
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        "active": true,
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        "name": "Aetna",
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        "address": [
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          {
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            "line": [
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              "PO Box 14080"
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            ],
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            "city": "Lexington",
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            "district": "Fayette",
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            "state": "KY",
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            "postalCode": "40512-4079",
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            "country": "USA"
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          }
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        ]
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      }
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    },
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    {
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      "resource": {
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        "resourceType": "Practitioner",
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        "id": "RedoxPractitionerExampleJoan",
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        "identifier": [
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          {
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            "system": "http://hl7.org/fhir/sid/us-npi",
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            "value": "4336749876"
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          }
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        ],
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        "name": [
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          {
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            "given": [
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              "Joan"
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            ],
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            "family": "Fishman"
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          }
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        ],
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        "address": [
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          {
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            "line": [
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              "4762 Hickory St."
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            ],
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            "city": "Monroe",
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            "district": "Green",
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            "state": "WI",
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            "postalCode": "53566",
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            "country": "USA"
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          }
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        ],
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        "telecom": [
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          {
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            "value": "+16085558899"
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          }
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        ]
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      }
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    }
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  ]
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}'

Request Body Schema

  • 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, Array of ClaimResponse, Patient, Coverage, Location

    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
    • 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
          Array of 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, Array of adjudicationamounttype or Other

        Categorized monetary totals for the adjudication.

          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
            Array of 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
        Array of 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, Array of adjudicationamounttype, denialreason, allowedunits or 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.

            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
              Array of 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
        Array of adjudicationamounttype, denialreason or Other

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

          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
            Array of 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
            Array of 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
              Array of 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
        Array of 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.

Response fields and example

Example
json
1
"Operation Response"