ClaimResponse $respond

post/ClaimResponse/$respond
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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.

$respond

Send a general response to a claim submission from a healthcare organization. Review tips for responding to claims.

We support this asynchronous operation for completeness and compliance with the DaVinci PAS specification

Request parameters and payload

cURL request example

bash
1
curl 'https://api.redoxengine.com/fhir/R4/{destinationSlug}/{environmentFlag}/ClaimResponse/$respond' \
2
--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 '{
6
"resourceType": "Bundle",
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"id": "RedoxClaimResponseBundleComprehensiveExample",
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"type": "collection",
9
"identifier": {
10
"system": "urn:ietf:rfc:3986",
11
"value": "urn:uuid:59f129cf-2eca-4965-88f2-452558af1934"
12
},
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"timestamp": "2021-10-21T19:09:02.452Z",
14
"entry": [
15
{
16
"resource": {
17
"resourceType": "ClaimResponse",
18
"id": "RedoxPAClaimResponseExample",
19
"status": "active",
20
"use": "preauthorization",
21
"item": [
22
{
23
"adjudication": [
24
{
25
"category": {
26
"coding": [
27
{
28
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
29
"code": "submitted"
30
}
31
]
32
},
33
"extension": [
34
{
35
"extension": [
36
{
37
"url": "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-reviewActionCode",
38
"valueCodeableConcept": {
39
"coding": [
40
{
41
"code": "A1",
42
"system": "https://codesystem.x12.org/005010/306",
43
"display": "Certified in total"
44
}
45
]
46
}
47
},
48
{
49
"url": "number",
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"valueString": "AUTH1001"
51
}
52
],
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"url": "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-reviewAction"
54
}
55
]
56
}
57
],
58
"extension": [
59
{
60
"url": "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-administrationReferenceNumber",
61
"valueString": "REF456"
62
},
63
{
64
"url": "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemPreAuthIssueDate",
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"valueDate": "2021-08-23"
66
},
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{
68
"url": "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemPreAuthPeriod",
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"valuePeriod": {
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"start": "2021-08-23",
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"end": "2021-09-23"
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}
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},
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{
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"url": "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemTraceNumber",
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"valueIdentifier": {
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"value": "23462346"
78
}
79
},
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{
81
"extension": [
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{
83
"url": "productOrServiceCode",
84
"valueCodeableConcept": {
85
"coding": [
86
{
87
"code": "93451",
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"system": "http://www.ama-assn.org/go/cpt"
89
}
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],
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"text": "Right heart catheterization"
92
}
93
},
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{
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"url": "quantity",
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"valueQuantity": {
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"value": 1
98
}
99
},
100
{
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"url": "unitPrice",
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"valueMoney": {
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"value": 4966,
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"currency": "USD"
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}
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}
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],
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"url": "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemAuthorizedDetail"
109
}
110
],
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"itemSequence": 1
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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"
119
}
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]
121
},
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"patient": {
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"reference": "Patient/RedoxPABeneficiaryExample"
124
},
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"created": "2021-08-23T16:35:54.648Z",
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"insurer": {
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"reference": "Organization/RedoxPAInsurerOrganizationExample"
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},
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"requestor": {
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"reference": "Organization/RedoxPARequestorOrganizationExample"
131
},
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"request": {
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"reference": "Claim/RedoxPAServiceClaimExample",
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"identifier": {
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"type": {
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"coding": [
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{
138
"code": "ClaimID"
139
}
140
]
141
},
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"value": "urn:uuid:97b8d6d0-ac3d-411a-b32a-e1d237aceb6a"
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}
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},
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"outcome": "complete",
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"processNote": [
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{
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"text": "Covered under extended benefits"
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}
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]
151
}
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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"
174
}
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},
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{
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"resource": {
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"resourceType": "Coverage",
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"id": "RedoxPACoverageWithRelatedSubscriberExample",
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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"
191
}
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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": "RelatedPerson/RedoxPASubscriberExample"
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},
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"subscriberId": "M2346623"
206
}
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},
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{
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"resource": {
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"resourceType": "Organization",
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"id": "RedoxPARequestorOrganizationExample",
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"active": true,
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"name": "Good Health Clinics",
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"address": [
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{
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"line": [
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"123 Main St."
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],
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"city": "Madison",
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"district": "Dane",
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"state": "WI",
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"postalCode": "53703",
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"country": "USA"
224
}
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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": "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": "PractitionerRole",
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"id": "RedoxPAPractitionerRoleExamplePat",
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"practitioner": {
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"reference": "Practitioner/RedoxPAPractitionerExamplePat"
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},
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"organization": {
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"reference": "Organization/RedoxPARequestorOrganizationExample"
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},
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"location": [
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{
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"display": "1st Street Family Clinic"
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}
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],
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"specialty": [
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{
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"coding": [
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{
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"code": "394579002",
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"system": "http://snomed.info/sct",
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"display": "Cardiology"
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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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{
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"resource": {
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"resourceType": "Practitioner",
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"id": "RedoxPAPractitionerExamplePat",
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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": "4356789876"
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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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"Pat"
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],
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"family": "Granite"
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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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"123 Main St."
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],
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"city": "Madison",
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"district": "Dane",
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"state": "WI",
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"postalCode": "53703",
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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": "+16085551234"
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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": "RelatedPerson",
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"id": "RedoxPASubscriberExample",
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"patient": {
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"reference": "Patient/RedoxPABeneficiaryExample"
319
},
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"name": [
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{
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"given": [
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"Barbara"
324
],
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"family": "Bixby"
326
}
327
],
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"relationship": [
329
{
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"text": "Mother"
331
}
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]
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}
334
},
335
{
336
"resource": {
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"resourceType": "Claim",
338
"id": "RedoxPAServiceClaimExample",
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"status": "active",
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"use": "preauthorization",
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"insurance": [
342
{
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"focal": true,
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"sequence": 1,
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"coverage": {
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"reference": "Coverage/RedoxPACoverageExample"
347
}
348
}
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],
350
"item": [
351
{
352
"extension": [
353
{
354
"url": "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-requestedService",
355
"valueReference": {
356
"reference": "ServiceRequest/RedoxPAServiceRequestExample"
357
}
358
},
359
{
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"url": "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemTraceNumber",
361
"valueIdentifier": {
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"value": "23462346"
363
}
364
}
365
],
366
"sequence": 1,
367
"productOrService": {
368
"coding": [
369
{
370
"code": "93456",
371
"system": "http://www.ama-assn.org/go/cpt"
372
}
373
],
374
"text": "Coronary angiography with right heart catheterization"
375
}
376
}
377
],
378
"supportingInfo": [
379
{
380
"category": {
381
"coding": [
382
{
383
"system": "http://hl7.org/fhir/us/davinci-pas/CodeSystem/PASSupportingInfoType",
384
"code": "additionalInformation",
385
"display": "Send additional paperwork or supporting information is sent for the request."
386
}
387
]
388
},
389
"sequence": 1,
390
"valueReference": {
391
"reference": "DocumentReference/RedoxPADocumentReferenceExample"
392
}
393
},
394
{
395
"category": {
396
"coding": [
397
{
398
"system": "http://hl7.org/fhir/us/davinci-pas/CodeSystem/PASSupportingInfoType",
399
"code": "freeFormMessage",
400
"display": "Written Confirmation."
401
}
402
]
403
},
404
"sequence": 2,
405
"valueString": "1"
406
}
407
],
408
"identifier": [
409
{
410
"type": {
411
"coding": [
412
{
413
"code": "ClaimID"
414
}
415
]
416
},
417
"value": "urn:uuid:97b8d6d0-ac3d-411a-b32a-e1d237aceb6a"
418
}
419
],
420
"type": {
421
"coding": [
422
{
423
"code": "professional",
424
"system": "http://terminology.hl7.org/CodeSystem/claim-type"
425
}
426
]
427
},
428
"patient": {
429
"reference": "Patient/RedoxPABeneficiaryExample"
430
},
431
"created": "2021-09-02T18:44:13.307Z",
432
"enterer": {
433
"reference": "PractitionerRole/RedoxPAPractitionerRoleExamplePat"
434
},
435
"insurer": {
436
"reference": "Organization/RedoxPAInsurerOrganizationExample"
437
},
438
"provider": {
439
"reference": "Organization/RedoxPARequestorOrganizationExample"
440
},
441
"priority": {
442
"coding": [
443
{
444
"code": "normal",
445
"system": "http://terminology.hl7.org/CodeSystem/processpriority"
446
}
447
]
448
},
449
"diagnosis": [
450
{
451
"sequence": 1,
452
"diagnosisCodeableConcept": {
453
"coding": [
454
{
455
"code": "I42.9",
456
"system": "http://hl7.org/fhir/sid/icd-10-cm",
457
"display": "Cardiomyopathy, unspecified"
458
}
459
]
460
}
461
}
462
]
463
}
464
}
465
]
466
}'

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
  • timestamp
    required, string

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

  • entry
    required, Array of ClaimResponse, Patient, Coverage, Organization

    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.

      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
          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: 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
            Array of Boolean, String, CodeableConcept, Coding

            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.

            • 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
        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 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, Array of 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
            Array of reviewAction or Other

            An Extension

              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
              Array of code, number or Other

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

                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
                  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
            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
          Array of itemTraceNumber, preAuthIssueDate, preAuthPeriod, administrationReferenceNumber

          Additional information about the item

            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
        Array of 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.

Response fields and example

Example
json
1
"Operation Response"