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
cURL request example
Request Body Schema
- resourceTyperequired, string
Identifies the type of the resource
Value:Bundle - typerequired, string
Indicates the purpose of this bundle - how it is intended to be used.
Value:collection - timestamprequired, string
The date/time that the bundle was assembled - i.e. when the resources were placed in the bundle.
- entryrequired, 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.
- resourcerequired, object
This resource provides the adjudication details from the processing of a Claim resource.
- resourceTyperequired, string
Identifies the type of the resource
Value:ClaimResponse - statusrequired, string
The status of the resource instance.
Value:active - typerequired, object
Type of claim. Example Codes
For prescriptions, typically
code='pharmacy'andsystem='http://terminology.hl7.org/CodeSystem/claim-type'- codingArray of object
A reference to a code defined by a terminology system.
- systemstring
The identification of the code system that defines the meaning of the symbol in the code.
- codestring
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).
- textstring
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.
- userequired, 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 - patientrequired, 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.- referencestring
A reference to a Patient resource
- createdrequired, string
The date this resource was created.
- insurerrequired, object
The party responsible for authorization, adjudication and reimbursement.
Must be a resource of type
Organization.- referencestring
A reference to an Organization resource
- outcomerequired, string
The outcome of the claim, predetermination, or preauthoirization processing.
queued|complete|error|partialPossible Values:queued,complete,error,partial - requestorobject
The provider which is responsible for the claim, predetermination or preauthorization.
Must be a resource of type
Organization.- referencestring
A reference to an Organization resource
- requestobject
A reference to the Claim resource triggering adjudication. This can be either the same
identifieras the originalClaim.identifieror elsereferencecan point to theClaim.idvalue. When sending only thereference, it is helpful to also include the original Claim resource in the request.Must be a resource of type
Claim.- referencestring
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. - identifierobject
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.
- extensionArray 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.
- urlrequired, string
Source of the definition for the extension code - a logical name or a URL.
- valueBooleanboolean
A single value for the extension.
- usestring
The purpose of this identifier.
Possible Values:usual,official,temp,secondary,old (If known) - systemstring
Establishes the namespace for the value - that is, a URL that describes a set values that are unique.
- valuestring
The portion of the identifier typically relevant to the user and which is unique within the context of the system.
- itemArray 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.
- itemSequencerequired, number
A number to uniquely reference the claim item entries.
- adjudicationrequired, 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.
- categoryrequired, object
Type of adjudication information. Example Codes
- codingrequired, Array of object
A reference to a code defined by a terminology system.
- systemrequired, string
The identification of the code system that defines the meaning of the symbol in the code.
Value:http://terminology.hl7.org/CodeSystem/adjudication - coderequired, 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
- textstring
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.
- extensionArray of reviewAction or Other
An Extension
- urlrequired, 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 - extensionArray of code, number or Other
Details of the review action that is necessary for the authorization, carried in sub-extension properties.
- urlrequired, 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 - valueCodeableConceptobject
Code indicating the type of action, from the X12 306 code set.
- codingArray of object
A reference to a code defined by a terminology system.
- systemstring
The identification of the code system that defines the meaning of the symbol in the code.
- codestring
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).
- textstring
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.
The code describing the result of the review.
See http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-reviewActionCode for more information
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
- amountobject
Monetary amount associated with the category.
- valuenumber
Numerical value (with implicit precision).
- currencystring
ISO 4217 Currency Code (e.g. USD for US Dollar)
- valuenumber
Non-monetary value. Used, for example, when the adjudication is a percentage.
- extensionArray of itemTraceNumber, preAuthIssueDate, preAuthPeriod, administrationReferenceNumber
Additional information about the item
- urlrequired, 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 - valueIdentifierobject
Uniquely identifies this claim item
- valuestring
The portion of the identifier typically relevant to the user and which is unique within the context of the system.
Uniquely identifies this claim item. (2000F-TRN)
See http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemTraceNumber for more information
- processNoteArray of object
A note that describes or explains adjudication results in a human readable form.
- textrequired, string
The explanation or description associated with the processing.
An entry in a bundle resource - will either contain a resource or information about a resource (transactions and history only).