LinuxForHealth FHIR Implementation Guide - Local Development build (v8.0.0). See the Directory of published versions

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Resource Profile: CDM Claim Response Drug

This resource provides the adjudication details from the processing of a Claim resource. The CDMClaimResponseDrug profile extends the CDMClaimResponse resource with additional adjudication details that are specific to pharmacy claims.

Usage:

• Examples for this Resource Profile: ClaimResponse/CDMClaimResponseDrugInstance

Formal Views of Profile Content

Description of Profiles, Differentials, Snapshots and how the different presentations work.

• Differential Table
• Key Elements Table
• Snapshot Table
• Statistics/References
• All

This structure is derived from CDMClaimResponse

Name	Flags	Card.	Type	Description & Constraints
ClaimResponse		0..*	CDMClaimResponse	Response to a claim predetermination or preauthorization
item
usualAndCustomaryAmount		0..1	decimal	Usual and customary amount on the drug claim URL: http://linuxforhealth.org/fhir/cdm/StructureDefinition/usual-and-customary-amount
rxFormularyIndicator		0..1	string	Indicates whether the prescription drug is included in the formulary URL: http://linuxforhealth.org/fhir/cdm/StructureDefinition/rx-formulary-indicator
rxPayTier		0..1	CodeableConcept	Customer-specific code for the payment tier of the drug Claim URL: http://linuxforhealth.org/fhir/cdm/StructureDefinition/rx-pay-tier
rxSupplyIndicator		0..1	string	Indicates whether the drug claim is a medical supply (Y) or a drug (N) URL: http://linuxforhealth.org/fhir/cdm/StructureDefinition/rx-supply-indicator
Documentation for this format

Name	Flags	Card.	Type	Description & Constraints
ClaimResponse		0..*	CDMClaimResponse	Response to a claim predetermination or preauthorization
implicitRules	?!Σ	0..1	uri	A set of rules under which this content was created
claimReceivedDate		0..1	date	Date the claim was received URL: http://linuxforhealth.org/fhir/cdm/StructureDefinition/claim-received-date
claimStatus		0..1	CodeableConcept	Custom code for the claim status URL: http://linuxforhealth.org/fhir/cdm/StructureDefinition/claim-status
daysToProcess		0..1	integer	Number of days between the date the claim was received and the date the claim was processed URL: http://linuxforhealth.org/fhir/cdm/StructureDefinition/days-to-process
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored
identifier		1..*	Identifier	Business Identifier for a claim response
use	?!Σ	0..1	code	usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .
system	Σ	1..1	uri	The namespace for the identifier value Example General: http://www.acme.com/identifiers/patient
value	Σ	1..1	string	The value that is unique Example General: 123456
status	?!Σ	1..1	code	active | cancelled | draft | entered-in-error Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance.
type	Σ	1..1	CodeableConcept	More granular claim type Binding: Claim Type Value Set (extensible)
use	Σ	1..1	code	claim | preauthorization | predetermination Binding: Use (required): Claim, preauthorization, predetermination.
patient	Σ	1..1	Reference(Patient)	The recipient of the products and services
created	Σ	1..1	dateTime	Response creation date
insurer	Σ	1..1	Reference(Organization)	Party responsible for reimbursement
outcome	Σ	1..1	code	queued | complete | error | partial Binding: ClaimProcessingCodes (required): The result of the claim processing.
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet
ClaimResponse.identifier.use	required	IdentifierUse
ClaimResponse.status	required	FinancialResourceStatusCodes
ClaimResponse.type	extensible	ClaimTypeValueSet (a valid code from Payer Claim Type Codes)
ClaimResponse.use	required	Use
ClaimResponse.outcome	required	ClaimProcessingCodes

Name	Flags	Card.	Type	Description & Constraints
ClaimResponse		0..*	CDMClaimResponse	Response to a claim predetermination or preauthorization
id	Σ	0..1	id	Logical id of this artifact
meta		0..1	ProcessMeta	Metadata about a resource
implicitRules	?!Σ	0..1	uri	A set of rules under which this content was created
language		0..1	code	Language of the resource content Binding: CommonLanguages (preferred): A human language. Additional Bindings Purpose AllLanguages Max Binding
text		0..1	Narrative	Text summary of the resource, for human interpretation
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
claimReceivedDate		0..1	date	Date the claim was received URL: http://linuxforhealth.org/fhir/cdm/StructureDefinition/claim-received-date
claimStatus		0..1	CodeableConcept	Custom code for the claim status URL: http://linuxforhealth.org/fhir/cdm/StructureDefinition/claim-status
daysToProcess		0..1	integer	Number of days between the date the claim was received and the date the claim was processed URL: http://linuxforhealth.org/fhir/cdm/StructureDefinition/days-to-process
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored
identifier		1..*	Identifier	Business Identifier for a claim response
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
use	?!Σ	0..1	code	usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .
type	Σ	0..1	CodeableConcept	Description of identifier Binding: Identifier Type Value Set (extensible)
system	Σ	1..1	uri	The namespace for the identifier value Example General: http://www.acme.com/identifiers/patient
value	Σ	1..1	string	The value that is unique Example General: 123456
period	Σ	0..1	Period	Time period when id is/was valid for use
assigner	Σ	0..1	Reference(Organization)	Organization that issued id (may be just text)
status	?!Σ	1..1	code	active | cancelled | draft | entered-in-error Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance.
type	Σ	1..1	CodeableConcept	More granular claim type Binding: Claim Type Value Set (extensible)
subType		0..1	CodeableConcept	More granular claim type Binding: ExampleClaimSubTypeCodes (example): A more granular claim typecode.
use	Σ	1..1	code	claim | preauthorization | predetermination Binding: Use (required): Claim, preauthorization, predetermination.
patient	Σ	1..1	Reference(Patient)	The recipient of the products and services
created	Σ	1..1	dateTime	Response creation date
insurer	Σ	1..1	Reference(Organization)	Party responsible for reimbursement
requestor		0..1	Reference(Practitioner | PractitionerRole | Organization)	Party responsible for the claim
request	Σ	0..1	Reference(Claim)	Id of resource triggering adjudication
outcome	Σ	1..1	code	queued | complete | error | partial Binding: ClaimProcessingCodes (required): The result of the claim processing.
disposition		0..1	string	Disposition Message
preAuthRef		0..1	string	Preauthorization reference
preAuthPeriod		0..1	Period	Preauthorization reference effective period
payeeType		0..1	CodeableConcept	Party to be paid any benefits payable Binding: Claim Payee Type Codes (example): A code for the party to be reimbursed.
item		0..*	BackboneElement	Adjudication for claim line items
id		0..1	string	Unique id for inter-element referencing
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
claimResponseItemStatus		0..1	CodeableConcept	The status of claim payment on claim item URL: http://linuxforhealth.org/fhir/cdm/StructureDefinition/claim-response-item-status Binding: Payer Claim Status Codes Value Set (extensible)
claimResponseBenefitPlan		0..1	Reference(Coverage)	The benefit plan that covers the service rendered URL: http://linuxforhealth.org/fhir/cdm/StructureDefinition/claim-response-benefit-plan
copayExclusion		0..1	CodeableConcept	Customer-specific code for the exclusion reason of a copayment URL: http://linuxforhealth.org/fhir/cdm/StructureDefinition/copay-exclusion
numberOfUnitsAllowed		0..1	integer	Customer-specific quantity of services or units allowed URL: http://linuxforhealth.org/fhir/cdm/StructureDefinition/number-of-units-allowed
reinsuranceMetIndicator		0..1	string	Indicator that the reinsurance amount was met URL: http://linuxforhealth.org/fhir/cdm/StructureDefinition/reinsurance-met-indicator
utilizationReview		0..1	CodeableConcept	Customer-specific code for the type of utilization review URL: http://linuxforhealth.org/fhir/cdm/StructureDefinition/utilization-review
usualAndCustomaryAmount		0..1	decimal	Usual and customary amount on the drug claim URL: http://linuxforhealth.org/fhir/cdm/StructureDefinition/usual-and-customary-amount
rxFormularyIndicator		0..1	string	Indicates whether the prescription drug is included in the formulary URL: http://linuxforhealth.org/fhir/cdm/StructureDefinition/rx-formulary-indicator
rxPayTier		0..1	CodeableConcept	Customer-specific code for the payment tier of the drug Claim URL: http://linuxforhealth.org/fhir/cdm/StructureDefinition/rx-pay-tier
rxSupplyIndicator		0..1	string	Indicates whether the drug claim is a medical supply (Y) or a drug (N) URL: http://linuxforhealth.org/fhir/cdm/StructureDefinition/rx-supply-indicator
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
itemSequence		1..1	positiveInt	Claim item instance identifier
noteNumber		0..*	positiveInt	Applicable note numbers
adjudication		1..*	BackboneElement	Adjudication details
id		0..1	string	Unique id for inter-element referencing
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
routingNumberCode		0..1	string	Customer-specific code for the ITS routing number URL: http://linuxforhealth.org/fhir/cdm/StructureDefinition/routing-number-code
savingsType		0..1	CodeableConcept	Customer-specific code for the type of third party savings URL: http://linuxforhealth.org/fhir/cdm/StructureDefinition/savings-type
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
category		1..1	CodeableConcept	Type of adjudication information Binding: Adjudication Category Value Set (example)
reason		0..1	CodeableConcept	Explanation of adjudication outcome Binding: AdjudicationReasonCodes (example): The adjudication reason codes.
amount		0..1	Money	Monetary amount
value		0..1	decimal	Non-monetary value
detail		0..*	BackboneElement	Adjudication for claim details
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
detailSequence		1..1	positiveInt	Claim detail instance identifier
noteNumber		0..*	positiveInt	Applicable note numbers
adjudication		1..*	See adjudication (ClaimResponse)	Detail level adjudication details
subDetail		0..*	BackboneElement	Adjudication for claim sub-details
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
subDetailSequence		1..1	positiveInt	Claim sub-detail instance identifier
noteNumber		0..*	positiveInt	Applicable note numbers
adjudication		0..*	See adjudication (ClaimResponse)	Subdetail level adjudication details
addItem		0..*	BackboneElement	Insurer added line items
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
itemSequence		0..*	positiveInt	Item sequence number
detailSequence		0..*	positiveInt	Detail sequence number
subdetailSequence		0..*	positiveInt	Subdetail sequence number
provider		0..*	Reference(Practitioner | PractitionerRole | Organization)	Authorized providers
productOrService		1..1	CodeableConcept	Billing, service, product, or drug code Binding: USCLSCodes (example): Allowable service and product codes.
modifier		0..*	CodeableConcept	Service/Product billing modifiers Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.
programCode		0..*	CodeableConcept	Program the product or service is provided under Binding: ExampleProgramReasonCodes (example): Program specific reason codes.
serviced[x]		0..1		Date or dates of service or product delivery
servicedDate			date
servicedPeriod			Period
location[x]		0..1		Place of service or where product was supplied Binding: ExampleServicePlaceCodes (example): Place of service: pharmacy, school, prison, etc.
locationCodeableConcept			CodeableConcept
locationAddress			Address
locationReference			Reference(Location)
quantity		0..1	SimpleQuantity	Count of products or services
unitPrice		0..1	Money	Fee, charge or cost per item
factor		0..1	decimal	Price scaling factor
net		0..1	Money	Total item cost
bodySite		0..1	CodeableConcept	Anatomical location Binding: OralSiteCodes (example): The code for the teeth, quadrant, sextant and arch.
subSite		0..*	CodeableConcept	Anatomical sub-location Binding: SurfaceCodes (example): The code for the tooth surface and surface combinations.
noteNumber		0..*	positiveInt	Applicable note numbers
adjudication		1..*	See adjudication (ClaimResponse)	Added items adjudication
detail		0..*	BackboneElement	Insurer added line details
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
productOrService		1..1	CodeableConcept	Billing, service, product, or drug code Binding: USCLSCodes (example): Allowable service and product codes.
modifier		0..*	CodeableConcept	Service/Product billing modifiers Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.
quantity		0..1	SimpleQuantity	Count of products or services
unitPrice		0..1	Money	Fee, charge or cost per item
factor		0..1	decimal	Price scaling factor
net		0..1	Money	Total item cost
noteNumber		0..*	positiveInt	Applicable note numbers
adjudication		1..*	See adjudication (ClaimResponse)	Added items detail adjudication
subDetail		0..*	BackboneElement	Insurer added line items
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
productOrService		1..1	CodeableConcept	Billing, service, product, or drug code Binding: USCLSCodes (example): Allowable service and product codes.
modifier		0..*	CodeableConcept	Service/Product billing modifiers Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.
quantity		0..1	SimpleQuantity	Count of products or services
unitPrice		0..1	Money	Fee, charge or cost per item
factor		0..1	decimal	Price scaling factor
net		0..1	Money	Total item cost
noteNumber		0..*	positiveInt	Applicable note numbers
adjudication		1..*	See adjudication (ClaimResponse)	Added items detail adjudication
adjudication		0..*	BackboneElement	Header-level adjudication
id		0..1	string	Unique id for inter-element referencing
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
adjudicationDate		0..1	date	Date on which the payment status of the claim was adjudicated URL: http://linuxforhealth.org/fhir/cdm/StructureDefinition/adjudication-date
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
category		1..1	CodeableConcept	Type of adjudication information Binding: AdjudicationValueCodes (example): The adjudication codes.
reason		0..1	CodeableConcept	Explanation of adjudication outcome Binding: AdjudicationReasonCodes (example): The adjudication reason codes.
amount		0..1	Money	Monetary amount
value		0..1	decimal	Non-monetary value
total	Σ	0..*	BackboneElement	Adjudication totals
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
category	Σ	1..1	CodeableConcept	Type of adjudication information Binding: AdjudicationValueCodes (example): The adjudication codes.
amount	Σ	1..1	Money	Financial total for the category
payment		0..1	BackboneElement	Payment Details
id		0..1	string	Unique id for inter-element referencing
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
claimAdjustmentType		0..*	CodeableConcept	The code for the type of adjustment for the claim URL: http://linuxforhealth.org/fhir/cdm/StructureDefinition/claim-adjustment-type Binding: Payer Claim Adjustment Type Value Set (extensible)
dispositionReason		0..*	CodeableConcept	Customer-specific code for the disposition reason, as related to how the claim was paid URL: http://linuxforhealth.org/fhir/cdm/StructureDefinition/disposition-reason
reimburseType		0..1	CodeableConcept	Method of payment code for the claim URL: http://linuxforhealth.org/fhir/cdm/StructureDefinition/reimburse-type
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
type		1..1	CodeableConcept	Partial or complete payment Binding: ExamplePaymentTypeCodes (example): The type (partial, complete) of the payment.
adjustment		0..1	Money	Payment adjustment for non-claim issues
adjustmentReason		0..1	CodeableConcept	Explanation for the adjustment Binding: PaymentAdjustmentReasonCodes (example): Payment Adjustment reason codes.
date		0..1	date	Expected date of payment
amount		1..1	Money	Payable amount after adjustment
identifier		0..1	Identifier	Business identifier for the payment
fundsReserve		0..1	CodeableConcept	Funds reserved status Binding: Funds Reservation Codes (example): For whom funds are to be reserved: (Patient, Provider, None).
formCode		0..1	CodeableConcept	Printed form identifier Binding: Form Codes (example): The forms codes.
form		0..1	Attachment	Printed reference or actual form
processNote		0..*	BackboneElement	Note concerning adjudication
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
number		0..1	positiveInt	Note instance identifier
type		0..1	code	display | print | printoper Binding: NoteType (required): The presentation types of notes.
text		1..1	string	Note explanatory text
language		0..1	CodeableConcept	Language of the text Binding: CommonLanguages (preferred): A human language. Additional Bindings Purpose AllLanguages Max Binding
communicationRequest		0..*	Reference(CommunicationRequest)	Request for additional information
insurance		0..*	BackboneElement	Patient insurance information
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
sequence		1..1	positiveInt	Insurance instance identifier
focal		1..1	boolean	Coverage to be used for adjudication
coverage		1..1	Reference(Coverage)	Insurance information
businessArrangement		0..1	string	Additional provider contract number
claimResponse		0..1	Reference(ClaimResponse)	Adjudication results
error		0..*	BackboneElement	Processing errors
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
itemSequence		0..1	positiveInt	Item sequence number
detailSequence		0..1	positiveInt	Detail sequence number
subDetailSequence		0..1	positiveInt	Subdetail sequence number
code		1..1	CodeableConcept	Error code detailing processing issues Binding: Adjudication Error Codes (example): The adjudication error codes.
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet
ClaimResponse.language	preferred	CommonLanguages Additional Bindings Purpose AllLanguages Max Binding
ClaimResponse.identifier.use	required	IdentifierUse
ClaimResponse.identifier.type	extensible	IdentifierTypeValueSet
ClaimResponse.status	required	FinancialResourceStatusCodes
ClaimResponse.type	extensible	ClaimTypeValueSet (a valid code from Payer Claim Type Codes)
ClaimResponse.subType	example	ExampleClaimSubTypeCodes
ClaimResponse.use	required	Use
ClaimResponse.outcome	required	ClaimProcessingCodes
ClaimResponse.payeeType	example	Claim Payee Type Codes
ClaimResponse.item.adjudication.category	example	AdjudicationCategoryValueSet (a valid code from Adjudication Category Codes)
ClaimResponse.item.adjudication.reason	example	AdjudicationReasonCodes
ClaimResponse.addItem.productOrService	example	USCLSCodes
ClaimResponse.addItem.modifier	example	ModifierTypeCodes
ClaimResponse.addItem.programCode	example	ExampleProgramReasonCodes
ClaimResponse.addItem.location[x]	example	ExampleServicePlaceCodes
ClaimResponse.addItem.bodySite	example	OralSiteCodes
ClaimResponse.addItem.subSite	example	SurfaceCodes
ClaimResponse.addItem.detail.productOrService	example	USCLSCodes
ClaimResponse.addItem.detail.modifier	example	ModifierTypeCodes
ClaimResponse.addItem.detail.subDetail.productOrService	example	USCLSCodes
ClaimResponse.addItem.detail.subDetail.modifier	example	ModifierTypeCodes
ClaimResponse.adjudication.category	example	AdjudicationValueCodes
ClaimResponse.adjudication.reason	example	AdjudicationReasonCodes
ClaimResponse.total.category	example	AdjudicationValueCodes
ClaimResponse.payment.type	example	ExamplePaymentTypeCodes
ClaimResponse.payment.adjustmentReason	example	PaymentAdjustmentReasonCodes
ClaimResponse.fundsReserve	example	Funds Reservation Codes
ClaimResponse.formCode	example	Form Codes
ClaimResponse.processNote.type	required	NoteType
ClaimResponse.processNote.language	preferred	CommonLanguages Additional Bindings Purpose AllLanguages Max Binding
ClaimResponse.error.code	example	Adjudication Error Codes

This structure is derived from CDMClaimResponse

Summary

Extensions

This structure refers to these extensions:

• http://linuxforhealth.org/fhir/cdm/StructureDefinition/usual-and-customary-amount
• http://linuxforhealth.org/fhir/cdm/StructureDefinition/rx-formulary-indicator
• http://linuxforhealth.org/fhir/cdm/StructureDefinition/rx-pay-tier
• http://linuxforhealth.org/fhir/cdm/StructureDefinition/rx-supply-indicator

Differential View

This structure is derived from CDMClaimResponse

Name	Flags	Card.	Type	Description & Constraints
ClaimResponse		0..*	CDMClaimResponse	Response to a claim predetermination or preauthorization
item
usualAndCustomaryAmount		0..1	decimal	Usual and customary amount on the drug claim URL: http://linuxforhealth.org/fhir/cdm/StructureDefinition/usual-and-customary-amount
rxFormularyIndicator		0..1	string	Indicates whether the prescription drug is included in the formulary URL: http://linuxforhealth.org/fhir/cdm/StructureDefinition/rx-formulary-indicator
rxPayTier		0..1	CodeableConcept	Customer-specific code for the payment tier of the drug Claim URL: http://linuxforhealth.org/fhir/cdm/StructureDefinition/rx-pay-tier
rxSupplyIndicator		0..1	string	Indicates whether the drug claim is a medical supply (Y) or a drug (N) URL: http://linuxforhealth.org/fhir/cdm/StructureDefinition/rx-supply-indicator
Documentation for this format

Key Elements View

Name	Flags	Card.	Type	Description & Constraints
ClaimResponse		0..*	CDMClaimResponse	Response to a claim predetermination or preauthorization
implicitRules	?!Σ	0..1	uri	A set of rules under which this content was created
claimReceivedDate		0..1	date	Date the claim was received URL: http://linuxforhealth.org/fhir/cdm/StructureDefinition/claim-received-date
claimStatus		0..1	CodeableConcept	Custom code for the claim status URL: http://linuxforhealth.org/fhir/cdm/StructureDefinition/claim-status
daysToProcess		0..1	integer	Number of days between the date the claim was received and the date the claim was processed URL: http://linuxforhealth.org/fhir/cdm/StructureDefinition/days-to-process
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored
identifier		1..*	Identifier	Business Identifier for a claim response
use	?!Σ	0..1	code	usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .
system	Σ	1..1	uri	The namespace for the identifier value Example General: http://www.acme.com/identifiers/patient
value	Σ	1..1	string	The value that is unique Example General: 123456
status	?!Σ	1..1	code	active | cancelled | draft | entered-in-error Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance.
type	Σ	1..1	CodeableConcept	More granular claim type Binding: Claim Type Value Set (extensible)
use	Σ	1..1	code	claim | preauthorization | predetermination Binding: Use (required): Claim, preauthorization, predetermination.
patient	Σ	1..1	Reference(Patient)	The recipient of the products and services
created	Σ	1..1	dateTime	Response creation date
insurer	Σ	1..1	Reference(Organization)	Party responsible for reimbursement
outcome	Σ	1..1	code	queued | complete | error | partial Binding: ClaimProcessingCodes (required): The result of the claim processing.
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet
ClaimResponse.identifier.use	required	IdentifierUse
ClaimResponse.status	required	FinancialResourceStatusCodes
ClaimResponse.type	extensible	ClaimTypeValueSet (a valid code from Payer Claim Type Codes)
ClaimResponse.use	required	Use
ClaimResponse.outcome	required	ClaimProcessingCodes

Snapshot View

Name	Flags	Card.	Type	Description & Constraints
ClaimResponse		0..*	CDMClaimResponse	Response to a claim predetermination or preauthorization
id	Σ	0..1	id	Logical id of this artifact
meta		0..1	ProcessMeta	Metadata about a resource
implicitRules	?!Σ	0..1	uri	A set of rules under which this content was created
language		0..1	code	Language of the resource content Binding: CommonLanguages (preferred): A human language. Additional Bindings Purpose AllLanguages Max Binding
text		0..1	Narrative	Text summary of the resource, for human interpretation
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
claimReceivedDate		0..1	date	Date the claim was received URL: http://linuxforhealth.org/fhir/cdm/StructureDefinition/claim-received-date
claimStatus		0..1	CodeableConcept	Custom code for the claim status URL: http://linuxforhealth.org/fhir/cdm/StructureDefinition/claim-status
daysToProcess		0..1	integer	Number of days between the date the claim was received and the date the claim was processed URL: http://linuxforhealth.org/fhir/cdm/StructureDefinition/days-to-process
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored
identifier		1..*	Identifier	Business Identifier for a claim response
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
use	?!Σ	0..1	code	usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .
type	Σ	0..1	CodeableConcept	Description of identifier Binding: Identifier Type Value Set (extensible)
system	Σ	1..1	uri	The namespace for the identifier value Example General: http://www.acme.com/identifiers/patient
value	Σ	1..1	string	The value that is unique Example General: 123456
period	Σ	0..1	Period	Time period when id is/was valid for use
assigner	Σ	0..1	Reference(Organization)	Organization that issued id (may be just text)
status	?!Σ	1..1	code	active | cancelled | draft | entered-in-error Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance.
type	Σ	1..1	CodeableConcept	More granular claim type Binding: Claim Type Value Set (extensible)
subType		0..1	CodeableConcept	More granular claim type Binding: ExampleClaimSubTypeCodes (example): A more granular claim typecode.
use	Σ	1..1	code	claim | preauthorization | predetermination Binding: Use (required): Claim, preauthorization, predetermination.
patient	Σ	1..1	Reference(Patient)	The recipient of the products and services
created	Σ	1..1	dateTime	Response creation date
insurer	Σ	1..1	Reference(Organization)	Party responsible for reimbursement
requestor		0..1	Reference(Practitioner | PractitionerRole | Organization)	Party responsible for the claim
request	Σ	0..1	Reference(Claim)	Id of resource triggering adjudication
outcome	Σ	1..1	code	queued | complete | error | partial Binding: ClaimProcessingCodes (required): The result of the claim processing.
disposition		0..1	string	Disposition Message
preAuthRef		0..1	string	Preauthorization reference
preAuthPeriod		0..1	Period	Preauthorization reference effective period
payeeType		0..1	CodeableConcept	Party to be paid any benefits payable Binding: Claim Payee Type Codes (example): A code for the party to be reimbursed.
item		0..*	BackboneElement	Adjudication for claim line items
id		0..1	string	Unique id for inter-element referencing
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
claimResponseItemStatus		0..1	CodeableConcept	The status of claim payment on claim item URL: http://linuxforhealth.org/fhir/cdm/StructureDefinition/claim-response-item-status Binding: Payer Claim Status Codes Value Set (extensible)
claimResponseBenefitPlan		0..1	Reference(Coverage)	The benefit plan that covers the service rendered URL: http://linuxforhealth.org/fhir/cdm/StructureDefinition/claim-response-benefit-plan
copayExclusion		0..1	CodeableConcept	Customer-specific code for the exclusion reason of a copayment URL: http://linuxforhealth.org/fhir/cdm/StructureDefinition/copay-exclusion
numberOfUnitsAllowed		0..1	integer	Customer-specific quantity of services or units allowed URL: http://linuxforhealth.org/fhir/cdm/StructureDefinition/number-of-units-allowed
reinsuranceMetIndicator		0..1	string	Indicator that the reinsurance amount was met URL: http://linuxforhealth.org/fhir/cdm/StructureDefinition/reinsurance-met-indicator
utilizationReview		0..1	CodeableConcept	Customer-specific code for the type of utilization review URL: http://linuxforhealth.org/fhir/cdm/StructureDefinition/utilization-review
usualAndCustomaryAmount		0..1	decimal	Usual and customary amount on the drug claim URL: http://linuxforhealth.org/fhir/cdm/StructureDefinition/usual-and-customary-amount
rxFormularyIndicator		0..1	string	Indicates whether the prescription drug is included in the formulary URL: http://linuxforhealth.org/fhir/cdm/StructureDefinition/rx-formulary-indicator
rxPayTier		0..1	CodeableConcept	Customer-specific code for the payment tier of the drug Claim URL: http://linuxforhealth.org/fhir/cdm/StructureDefinition/rx-pay-tier
rxSupplyIndicator		0..1	string	Indicates whether the drug claim is a medical supply (Y) or a drug (N) URL: http://linuxforhealth.org/fhir/cdm/StructureDefinition/rx-supply-indicator
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
itemSequence		1..1	positiveInt	Claim item instance identifier
noteNumber		0..*	positiveInt	Applicable note numbers
adjudication		1..*	BackboneElement	Adjudication details
id		0..1	string	Unique id for inter-element referencing
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
routingNumberCode		0..1	string	Customer-specific code for the ITS routing number URL: http://linuxforhealth.org/fhir/cdm/StructureDefinition/routing-number-code
savingsType		0..1	CodeableConcept	Customer-specific code for the type of third party savings URL: http://linuxforhealth.org/fhir/cdm/StructureDefinition/savings-type
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
category		1..1	CodeableConcept	Type of adjudication information Binding: Adjudication Category Value Set (example)
reason		0..1	CodeableConcept	Explanation of adjudication outcome Binding: AdjudicationReasonCodes (example): The adjudication reason codes.
amount		0..1	Money	Monetary amount
value		0..1	decimal	Non-monetary value
detail		0..*	BackboneElement	Adjudication for claim details
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
detailSequence		1..1	positiveInt	Claim detail instance identifier
noteNumber		0..*	positiveInt	Applicable note numbers
adjudication		1..*	See adjudication (ClaimResponse)	Detail level adjudication details
subDetail		0..*	BackboneElement	Adjudication for claim sub-details
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
subDetailSequence		1..1	positiveInt	Claim sub-detail instance identifier
noteNumber		0..*	positiveInt	Applicable note numbers
adjudication		0..*	See adjudication (ClaimResponse)	Subdetail level adjudication details
addItem		0..*	BackboneElement	Insurer added line items
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
itemSequence		0..*	positiveInt	Item sequence number
detailSequence		0..*	positiveInt	Detail sequence number
subdetailSequence		0..*	positiveInt	Subdetail sequence number
provider		0..*	Reference(Practitioner | PractitionerRole | Organization)	Authorized providers
productOrService		1..1	CodeableConcept	Billing, service, product, or drug code Binding: USCLSCodes (example): Allowable service and product codes.
modifier		0..*	CodeableConcept	Service/Product billing modifiers Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.
programCode		0..*	CodeableConcept	Program the product or service is provided under Binding: ExampleProgramReasonCodes (example): Program specific reason codes.
serviced[x]		0..1		Date or dates of service or product delivery
servicedDate			date
servicedPeriod			Period
location[x]		0..1		Place of service or where product was supplied Binding: ExampleServicePlaceCodes (example): Place of service: pharmacy, school, prison, etc.
locationCodeableConcept			CodeableConcept
locationAddress			Address
locationReference			Reference(Location)
quantity		0..1	SimpleQuantity	Count of products or services
unitPrice		0..1	Money	Fee, charge or cost per item
factor		0..1	decimal	Price scaling factor
net		0..1	Money	Total item cost
bodySite		0..1	CodeableConcept	Anatomical location Binding: OralSiteCodes (example): The code for the teeth, quadrant, sextant and arch.
subSite		0..*	CodeableConcept	Anatomical sub-location Binding: SurfaceCodes (example): The code for the tooth surface and surface combinations.
noteNumber		0..*	positiveInt	Applicable note numbers
adjudication		1..*	See adjudication (ClaimResponse)	Added items adjudication
detail		0..*	BackboneElement	Insurer added line details
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
productOrService		1..1	CodeableConcept	Billing, service, product, or drug code Binding: USCLSCodes (example): Allowable service and product codes.
modifier		0..*	CodeableConcept	Service/Product billing modifiers Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.
quantity		0..1	SimpleQuantity	Count of products or services
unitPrice		0..1	Money	Fee, charge or cost per item
factor		0..1	decimal	Price scaling factor
net		0..1	Money	Total item cost
noteNumber		0..*	positiveInt	Applicable note numbers
adjudication		1..*	See adjudication (ClaimResponse)	Added items detail adjudication
subDetail		0..*	BackboneElement	Insurer added line items
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
productOrService		1..1	CodeableConcept	Billing, service, product, or drug code Binding: USCLSCodes (example): Allowable service and product codes.
modifier		0..*	CodeableConcept	Service/Product billing modifiers Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.
quantity		0..1	SimpleQuantity	Count of products or services
unitPrice		0..1	Money	Fee, charge or cost per item
factor		0..1	decimal	Price scaling factor
net		0..1	Money	Total item cost
noteNumber		0..*	positiveInt	Applicable note numbers
adjudication		1..*	See adjudication (ClaimResponse)	Added items detail adjudication
adjudication		0..*	BackboneElement	Header-level adjudication
id		0..1	string	Unique id for inter-element referencing
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
adjudicationDate		0..1	date	Date on which the payment status of the claim was adjudicated URL: http://linuxforhealth.org/fhir/cdm/StructureDefinition/adjudication-date
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
category		1..1	CodeableConcept	Type of adjudication information Binding: AdjudicationValueCodes (example): The adjudication codes.
reason		0..1	CodeableConcept	Explanation of adjudication outcome Binding: AdjudicationReasonCodes (example): The adjudication reason codes.
amount		0..1	Money	Monetary amount
value		0..1	decimal	Non-monetary value
total	Σ	0..*	BackboneElement	Adjudication totals
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
category	Σ	1..1	CodeableConcept	Type of adjudication information Binding: AdjudicationValueCodes (example): The adjudication codes.
amount	Σ	1..1	Money	Financial total for the category
payment		0..1	BackboneElement	Payment Details
id		0..1	string	Unique id for inter-element referencing
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
claimAdjustmentType		0..*	CodeableConcept	The code for the type of adjustment for the claim URL: http://linuxforhealth.org/fhir/cdm/StructureDefinition/claim-adjustment-type Binding: Payer Claim Adjustment Type Value Set (extensible)
dispositionReason		0..*	CodeableConcept	Customer-specific code for the disposition reason, as related to how the claim was paid URL: http://linuxforhealth.org/fhir/cdm/StructureDefinition/disposition-reason
reimburseType		0..1	CodeableConcept	Method of payment code for the claim URL: http://linuxforhealth.org/fhir/cdm/StructureDefinition/reimburse-type
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
type		1..1	CodeableConcept	Partial or complete payment Binding: ExamplePaymentTypeCodes (example): The type (partial, complete) of the payment.
adjustment		0..1	Money	Payment adjustment for non-claim issues
adjustmentReason		0..1	CodeableConcept	Explanation for the adjustment Binding: PaymentAdjustmentReasonCodes (example): Payment Adjustment reason codes.
date		0..1	date	Expected date of payment
amount		1..1	Money	Payable amount after adjustment
identifier		0..1	Identifier	Business identifier for the payment
fundsReserve		0..1	CodeableConcept	Funds reserved status Binding: Funds Reservation Codes (example): For whom funds are to be reserved: (Patient, Provider, None).
formCode		0..1	CodeableConcept	Printed form identifier Binding: Form Codes (example): The forms codes.
form		0..1	Attachment	Printed reference or actual form
processNote		0..*	BackboneElement	Note concerning adjudication
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
number		0..1	positiveInt	Note instance identifier
type		0..1	code	display | print | printoper Binding: NoteType (required): The presentation types of notes.
text		1..1	string	Note explanatory text
language		0..1	CodeableConcept	Language of the text Binding: CommonLanguages (preferred): A human language. Additional Bindings Purpose AllLanguages Max Binding
communicationRequest		0..*	Reference(CommunicationRequest)	Request for additional information
insurance		0..*	BackboneElement	Patient insurance information
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
sequence		1..1	positiveInt	Insurance instance identifier
focal		1..1	boolean	Coverage to be used for adjudication
coverage		1..1	Reference(Coverage)	Insurance information
businessArrangement		0..1	string	Additional provider contract number
claimResponse		0..1	Reference(ClaimResponse)	Adjudication results
error		0..*	BackboneElement	Processing errors
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
itemSequence		0..1	positiveInt	Item sequence number
detailSequence		0..1	positiveInt	Detail sequence number
subDetailSequence		0..1	positiveInt	Subdetail sequence number
code		1..1	CodeableConcept	Error code detailing processing issues Binding: Adjudication Error Codes (example): The adjudication error codes.
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet
ClaimResponse.language	preferred	CommonLanguages Additional Bindings Purpose AllLanguages Max Binding
ClaimResponse.identifier.use	required	IdentifierUse
ClaimResponse.identifier.type	extensible	IdentifierTypeValueSet
ClaimResponse.status	required	FinancialResourceStatusCodes
ClaimResponse.type	extensible	ClaimTypeValueSet (a valid code from Payer Claim Type Codes)
ClaimResponse.subType	example	ExampleClaimSubTypeCodes
ClaimResponse.use	required	Use
ClaimResponse.outcome	required	ClaimProcessingCodes
ClaimResponse.payeeType	example	Claim Payee Type Codes
ClaimResponse.item.adjudication.category	example	AdjudicationCategoryValueSet (a valid code from Adjudication Category Codes)
ClaimResponse.item.adjudication.reason	example	AdjudicationReasonCodes
ClaimResponse.addItem.productOrService	example	USCLSCodes
ClaimResponse.addItem.modifier	example	ModifierTypeCodes
ClaimResponse.addItem.programCode	example	ExampleProgramReasonCodes
ClaimResponse.addItem.location[x]	example	ExampleServicePlaceCodes
ClaimResponse.addItem.bodySite	example	OralSiteCodes
ClaimResponse.addItem.subSite	example	SurfaceCodes
ClaimResponse.addItem.detail.productOrService	example	USCLSCodes
ClaimResponse.addItem.detail.modifier	example	ModifierTypeCodes
ClaimResponse.addItem.detail.subDetail.productOrService	example	USCLSCodes
ClaimResponse.addItem.detail.subDetail.modifier	example	ModifierTypeCodes
ClaimResponse.adjudication.category	example	AdjudicationValueCodes
ClaimResponse.adjudication.reason	example	AdjudicationReasonCodes
ClaimResponse.total.category	example	AdjudicationValueCodes
ClaimResponse.payment.type	example	ExamplePaymentTypeCodes
ClaimResponse.payment.adjustmentReason	example	PaymentAdjustmentReasonCodes
ClaimResponse.fundsReserve	example	Funds Reservation Codes
ClaimResponse.formCode	example	Form Codes
ClaimResponse.processNote.type	required	NoteType
ClaimResponse.processNote.language	preferred	CommonLanguages Additional Bindings Purpose AllLanguages Max Binding
ClaimResponse.error.code	example	Adjudication Error Codes

This structure is derived from CDMClaimResponse

Summary

Extensions

This structure refers to these extensions:

• http://linuxforhealth.org/fhir/cdm/StructureDefinition/usual-and-customary-amount
• http://linuxforhealth.org/fhir/cdm/StructureDefinition/rx-formulary-indicator
• http://linuxforhealth.org/fhir/cdm/StructureDefinition/rx-pay-tier
• http://linuxforhealth.org/fhir/cdm/StructureDefinition/rx-supply-indicator

Other representations of profile: CSV, Excel, Schematron