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    Class ClaimResponse

    ClaimResponse Class

    This resource provides the adjudication details from the processing of a Claim resource.

    FHIR Specification

    • Short: Response to a claim predetermination or preauthorization
    • Definition: This resource provides the adjudication details from the processing of a Claim resource.
    • FHIR Version: 5.0.0

    FHIR ClaimResponse

    Hierarchy (View Summary)

    Implements

    Index

    Constructors

    constructor

    Properties

    identifier? traceNumber? fmStatusEnum status type_ subType? claimUseEnum use patient created insurer? requestor? request? claimOutcomeEnum outcome decision? disposition? preAuthRef? preAuthPeriod? event? payeeType? encounter? diagnosisRelatedGroup? item? addItem_? adjudication? total? payment? fundsReserve? formCode? form? processNote? communicationRequest? insurance? error?

    Methods

    parse getIdentifier setIdentifier addIdentifier hasIdentifier getTraceNumber setTraceNumber addTraceNumber hasTraceNumber getStatusEnumType setStatusEnumType hasStatusEnumType getStatusElement setStatusElement hasStatusElement getStatus setStatus hasStatus getType setType hasType getSubType setSubType hasSubType getUseEnumType setUseEnumType hasUseEnumType getUseElement setUseElement hasUseElement getUse setUse hasUse getPatient setPatient hasPatient getCreatedElement setCreatedElement hasCreatedElement getCreated setCreated hasCreated getInsurer setInsurer hasInsurer getRequestor setRequestor hasRequestor getRequest setRequest hasRequest getOutcomeEnumType setOutcomeEnumType hasOutcomeEnumType getOutcomeElement setOutcomeElement hasOutcomeElement getOutcome setOutcome hasOutcome getDecision setDecision hasDecision getDispositionElement setDispositionElement hasDispositionElement getDisposition setDisposition hasDisposition getPreAuthRefElement setPreAuthRefElement hasPreAuthRefElement getPreAuthRef setPreAuthRef hasPreAuthRef getPreAuthPeriod setPreAuthPeriod hasPreAuthPeriod getEvent setEvent addEvent hasEvent getPayeeType setPayeeType hasPayeeType getEncounter setEncounter addEncounter hasEncounter getDiagnosisRelatedGroup setDiagnosisRelatedGroup hasDiagnosisRelatedGroup getItem setItem addItem hasItem getAddItem setAddItem addAddItem hasAddItem getAdjudication setAdjudication addAdjudication hasAdjudication getTotal setTotal addTotal hasTotal getPayment setPayment hasPayment getFundsReserve setFundsReserve hasFundsReserve getFormCode setFormCode hasFormCode getForm setForm hasForm getProcessNote setProcessNote addProcessNote hasProcessNote getCommunicationRequest setCommunicationRequest addCommunicationRequest hasCommunicationRequest getInsurance setInsurance addInsurance hasInsurance getError setError addError hasError fhirType isEmpty isRequiredFieldsEmpty copy toJSON getText setText hasText getContained setContained addContained hasContained getExtension setExtension hasExtension getExtensionByUrl addExtension removeExtension getModifierExtension setModifierExtension hasModifierExtension getModifierExtensionByUrl addModifierExtension removeModifierExtension resourceType getIdElement setIdElement hasIdElement getId setId hasId getMeta setMeta hasMeta getImplicitRulesElement setImplicitRulesElement hasImplicitRulesElement getImplicitRules setImplicitRules hasImplicitRules getLanguageElement setLanguageElement hasLanguageElement getLanguage setLanguage hasLanguage isResource isDataType isComplexDataType isPrimitive isBooleanPrimitive isStringPrimitive isNumberPrimitive isBigIntPrimitive isDateTimePrimitive copyValues initIdentifier initTraceNumber initEvent initEncounter initItem initAddItem initAdjudication initTotal initProcessNote initCommunicationRequest initInsurance initError

    Constructors

    Properties

    identifier?: Identifier[]

    ClaimResponse.identifier Element

    FHIR Specification

    • Short: Business Identifier for a claim response
    • Definition: A unique identifier assigned to this claim response.
    • Requirements: Allows claim responses to be distinguished and referenced.
    • FHIR Type: Identifier
    • Cardinality: 0..*
    • isModifier: false
    • isSummary: false
    traceNumber?: Identifier[]

    ClaimResponse.traceNumber Element

    FHIR Specification

    • Short: Number for tracking
    • Definition: Trace number for tracking purposes. May be defined at the jurisdiction level or between trading partners.
    • Requirements: Allows partners to uniquely identify components for tracking.
    • FHIR Type: Identifier
    • Cardinality: 0..*
    • isModifier: false
    • isSummary: false
    fmStatusEnum: FmStatusEnum

    FHIR CodeSystem: FmStatus

    FmStatusEnum

    status: null | EnumCodeType

    ClaimResponse.status Element

    FHIR Specification

    • Short: active | cancelled | draft | entered-in-error
    • Definition: The status of the resource instance.
    • Comment: This element is labeled as a modifier because the status contains codes that mark the resource as not currently valid.
    • Requirements: Need to track the status of the resource as 'draft' resources may undergo further edits while 'active' resources are immutable and may only have their status changed to 'cancelled'.
    • FHIR Type: code
    • Cardinality: 1..1
    • isModifier: true
    • isModifierReason: This element is labeled as a modifier because it is a status element that contains status entered-in-error which means that the resource should not be treated as valid
    • isSummary: true

    CodeSystem Enumeration: FmStatusEnum

    Privatetype_

    type_: null | CodeableConcept

    ClaimResponse.type Element

    FHIR Specification

    • Short: More granular claim type
    • Definition: A finer grained suite of claim type codes which may convey additional information such as Inpatient vs Outpatient and/or a specialty service.
    • Comment: This may contain the local bill type codes, for example the US UB-04 bill type code or the CMS bill type.
    • Requirements: Some jurisdictions need a finer grained claim type for routing and adjudication.
    • FHIR Type: CodeableConcept
    • Cardinality: 1..1
    • isModifier: false
    • isSummary: true
    subType?: CodeableConcept

    ClaimResponse.subType Element

    FHIR Specification

    • Short: More granular claim type
    • Definition: A finer grained suite of claim type codes which may convey additional information such as Inpatient vs Outpatient and/or a specialty service.
    • Comment: This may contain the local bill type codes, for example the US UB-04 bill type code or the CMS bill type.
    • Requirements: Some jurisdictions need a finer grained claim type for routing and adjudication.
    • FHIR Type: CodeableConcept
    • Cardinality: 0..1
    • isModifier: false
    • isSummary: false
    claimUseEnum: ClaimUseEnum

    FHIR CodeSystem: ClaimUse

    ClaimUseEnum

    use: null | EnumCodeType

    ClaimResponse.use Element

    FHIR Specification

    • Short: claim | preauthorization | predetermination
    • Definition: A code to indicate whether the nature of the request is: Claim - A request to an Insurer to adjudicate the supplied charges for health care goods and services under the identified policy and to pay the determined Benefit amount, if any; Preauthorization - A request to an Insurer to adjudicate the supplied proposed future charges for health care goods and services under the identified policy and to approve the services and provide the expected benefit amounts and potentially to reserve funds to pay the benefits when Claims for the indicated services are later submitted; or, Pre-determination - A request to an Insurer to adjudicate the supplied 'what if' charges for health care goods and services under the identified policy and report back what the Benefit payable would be had the services actually been provided.
    • Requirements: This element is required to understand the nature of the request for adjudication.
    • FHIR Type: code
    • Cardinality: 1..1
    • isModifier: false
    • isSummary: true

    CodeSystem Enumeration: ClaimUseEnum

    patient: null | Reference

    ClaimResponse.patient Element

    FHIR Specification

    • Short: The recipient of the products and services
    • Definition: 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.
    • Requirements: The patient must be supplied to the insurer so that confirmation of coverage and service hstory may be considered as part of the authorization and/or adjudiction.
    • FHIR Type: Reference
    • Cardinality: 1..1
    • isModifier: false
    • isSummary: true
    created: null | DateTimeType

    ClaimResponse.created Element

    FHIR Specification

    • Short: Response creation date
    • Definition: The date this resource was created.
    • Requirements: Need to record a timestamp for use by both the recipient and the issuer.
    • FHIR Type: dateTime
    • Cardinality: 1..1
    • isModifier: false
    • isSummary: true
    insurer?: Reference

    ClaimResponse.insurer Element

    FHIR Specification

    • Short: Party responsible for reimbursement
    • Definition: The party responsible for authorization, adjudication and reimbursement.
    • Requirements: To be a valid claim, preauthorization or predetermination there must be a party who is responsible for adjudicating the contents against a policy which provides benefits for the patient.
    • FHIR Type: Reference
    • Cardinality: 0..1
    • isModifier: false
    • isSummary: true
    requestor?: Reference

    ClaimResponse.requestor Element

    FHIR Specification

    request?: Reference

    ClaimResponse.request Element

    FHIR Specification

    • Short: Id of resource triggering adjudication
    • Definition: Original request resource reference.
    • FHIR Type: Reference
    • Cardinality: 0..1
    • isModifier: false
    • isSummary: true
    claimOutcomeEnum: ClaimOutcomeEnum

    FHIR CodeSystem: ClaimOutcome

    ClaimOutcomeEnum

    outcome: null | EnumCodeType

    ClaimResponse.outcome Element

    FHIR Specification

    • Short: queued | complete | error | partial
    • Definition: The outcome of the claim, predetermination, or preauthorization processing.
    • Comment: The resource may be used to indicate that the Claim/Preauthorization/Pre-determination has been received but processing has not begun (queued); that it has been processed and one or more errors have been detected (error); no errors were detected and some of the adjudication processing has been performed (partial); or all of the adjudication processing has completed without errors (complete).
    • Requirements: To advise the requestor of an overall processing outcome.
    • FHIR Type: code
    • Cardinality: 1..1
    • isModifier: false
    • isSummary: true

    CodeSystem Enumeration: ClaimOutcomeEnum

    decision?: CodeableConcept

    ClaimResponse.decision Element

    FHIR Specification

    • Short: Result of the adjudication
    • Definition: The result of the claim, predetermination, or preauthorization adjudication.
    • Comment: The element is used to indicate the current state of the adjudication overall for the claim resource, for example: the request has been held (pended) for adjudication processing, for manual review or other reasons; that it has been processed and will be paid, or the outstanding paid, as submitted (approved); that no amount will be paid (denied); or that some amount between zero and the submitted amount will be paid (partial).
    • Requirements: To advise the requestor of the result of the adjudication process.
    • FHIR Type: CodeableConcept
    • Cardinality: 0..1
    • isModifier: false
    • isSummary: true
    disposition?: StringType

    ClaimResponse.disposition Element

    FHIR Specification

    • Short: Disposition Message
    • Definition: A human readable description of the status of the adjudication.
    • Requirements: Provided for user display.
    • FHIR Type: string
    • Cardinality: 0..1
    • isModifier: false
    • isSummary: false
    preAuthRef?: StringType

    ClaimResponse.preAuthRef Element

    FHIR Specification

    • Short: Preauthorization reference
    • Definition: Reference from the Insurer which is used in later communications which refers to this adjudication.
    • Comment: This value is only present on preauthorization adjudications.
    • Requirements: On subsequent claims, the insurer may require the provider to quote this value.
    • FHIR Type: string
    • Cardinality: 0..1
    • isModifier: false
    • isSummary: false
    preAuthPeriod?: Period

    ClaimResponse.preAuthPeriod Element

    FHIR Specification

    • Short: Preauthorization reference effective period
    • Definition: The time frame during which this authorization is effective.
    • Requirements: To convey to the provider when the authorized products and services must be supplied for the authorized adjudication to apply.
    • FHIR Type: Period
    • Cardinality: 0..1
    • isModifier: false
    • isSummary: false
    event?: ClaimResponseEventComponent[]

    ClaimResponse.event Element

    FHIR Specification

    • Short: Event information
    • Definition: Information code for an event with a corresponding date or period.
    • FHIR Type: BackboneElement
    • Cardinality: 0..*
    • isModifier: false
    • isSummary: false
    payeeType?: CodeableConcept

    ClaimResponse.payeeType Element

    FHIR Specification

    • Short: Party to be paid any benefits payable
    • Definition: Type of Party to be reimbursed: subscriber, provider, other.
    • Requirements: Need to know who should receive payment with the most common situations being the Provider (assignment of benefits) or the Subscriber.
    • FHIR Type: CodeableConcept
    • Cardinality: 0..1
    • isModifier: false
    • isSummary: false
    encounter?: Reference[]

    ClaimResponse.encounter Element

    FHIR Specification

    • Short: Encounters associated with the listed treatments
    • Definition: Healthcare encounters related to this claim.
    • Comment: This will typically be the encounter the event occurred within, but some activities may be initiated prior to or after the official completion of an encounter but still be tied to the context of the encounter.
    • Requirements: Used in some jurisdictions to link clinical events to claim items.
    • FHIR Type: Reference
    • Cardinality: 0..*
    • isModifier: false
    • isSummary: false
    diagnosisRelatedGroup?: CodeableConcept

    ClaimResponse.diagnosisRelatedGroup Element

    FHIR Specification

    • Short: Package billing code
    • Definition: A package billing code or bundle code used to group products and services to a particular health condition (such as heart attack) which is based on a predetermined grouping code system.
    • Comment: For example DRG (Diagnosis Related Group) or a bundled billing code. A patient may have a diagnosis of a Myocardial Infarction and a DRG for HeartAttack would be assigned. The Claim item (and possible subsequent claims) would refer to the DRG for those line items that were for services related to the heart attack event.
    • Requirements: Required to relate the current diagnosis to a package billing code that is then referenced on the individual claim items which are specific to the health condition covered by the package code.
    • FHIR Type: CodeableConcept
    • Cardinality: 0..1
    • isModifier: false
    • isSummary: false
    item?: ClaimResponseItemComponent[]

    ClaimResponse.item Element

    FHIR Specification

    • Short: Adjudication for claim line items
    • Definition: 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.
    • Requirements: The adjudication for items provided on the claim.
    • FHIR Type: BackboneElement
    • Cardinality: 0..*
    • isModifier: false
    • isSummary: false

    Private OptionaladdItem_

    addItem_?: ClaimResponseAddItemComponent[]

    ClaimResponse.addItem Element

    FHIR Specification

    • Short: Insurer added line items
    • Definition: The first-tier service adjudications for payor added product or service lines.
    • Requirements: Insurers may redefine the provided product or service or may package and/or decompose groups of products and services. The addItems allows the insurer to provide their line item list with linkage to the submitted items/details/sub-details. In a preauthorization the insurer may use the addItem structure to provide additional information on authorized products and services.
    • FHIR Type: BackboneElement
    • Cardinality: 0..*
    • isModifier: false
    • isSummary: false
    adjudication?: ClaimResponseItemAdjudicationComponent[]

    ClaimResponse.adjudication Element

    FHIR Specification

    • Short: Header-level adjudication
    • Definition: The adjudication results which are presented at the header level rather than at the line-item or add-item levels.
    • Requirements: Some insurers will receive line-items but provide the adjudication only at a summary or header-level.
    • FHIR Type: BackboneElement
    • Cardinality: 0..*
    • isModifier: false
    • isSummary: false
    total?: ClaimResponseTotalComponent[]

    ClaimResponse.total Element

    FHIR Specification

    • Short: Adjudication totals
    • Definition: Categorized monetary totals for the adjudication.
    • Comment: Totals for amounts submitted, co-pays, benefits payable etc.
    • Requirements: To provide the requestor with financial totals by category for the adjudication.
    • FHIR Type: BackboneElement
    • Cardinality: 0..*
    • isModifier: false
    • isSummary: true
    payment?: ClaimResponsePaymentComponent

    ClaimResponse.payment Element

    FHIR Specification

    • Short: Payment Details
    • Definition: Payment details for the adjudication of the claim.
    • Requirements: Needed to convey references to the financial instrument that has been used if payment has been made.
    • FHIR Type: BackboneElement
    • Cardinality: 0..1
    • isModifier: false
    • isSummary: false
    fundsReserve?: CodeableConcept

    ClaimResponse.fundsReserve Element

    FHIR Specification

    • Short: Funds reserved status
    • Definition: A code, used only on a response to a preauthorization, to indicate whether the benefits payable have been reserved and for whom.
    • Comment: Fund would be release by a future claim quoting the preAuthRef of this response. Examples of values include: provider, patient, none.
    • Requirements: Needed to advise the submitting provider on whether the rquest for reservation of funds has been honored.
    • FHIR Type: CodeableConcept
    • Cardinality: 0..1
    • isModifier: false
    • isSummary: false
    formCode?: CodeableConcept

    ClaimResponse.formCode Element

    FHIR Specification

    • Short: Printed form identifier
    • Definition: A code for the form to be used for printing the content.
    • Comment: May be needed to identify specific jurisdictional forms.
    • Requirements: Needed to specify the specific form used for producing output for this response.
    • FHIR Type: CodeableConcept
    • Cardinality: 0..1
    • isModifier: false
    • isSummary: false
    form?: Attachment

    ClaimResponse.form Element

    FHIR Specification

    • Short: Printed reference or actual form
    • Definition: The actual form, by reference or inclusion, for printing the content or an EOB.
    • Comment: Needed to permit insurers to include the actual form.
    • Requirements: Needed to include the specific form used for producing output for this response.
    • FHIR Type: Attachment
    • Cardinality: 0..1
    • isModifier: false
    • isSummary: false
    processNote?: ClaimResponseProcessNoteComponent[]

    ClaimResponse.processNote Element

    FHIR Specification

    • Short: Note concerning adjudication
    • Definition: A note that describes or explains adjudication results in a human readable form.
    • Requirements: Provides the insurer specific textual explanations associated with the processing.
    • FHIR Type: BackboneElement
    • Cardinality: 0..*
    • isModifier: false
    • isSummary: false
    communicationRequest?: Reference[]

    ClaimResponse.communicationRequest Element

    FHIR Specification

    • Short: Request for additional information
    • Definition: Request for additional supporting or authorizing information.
    • Comment: For example: professional reports, documents, images, clinical resources, or accident reports.
    • Requirements: Need to communicate insurer request for additional information required to support the adjudication.
    • FHIR Type: Reference
    • Cardinality: 0..*
    • isModifier: false
    • isSummary: false
    insurance?: ClaimResponseInsuranceComponent[]

    ClaimResponse.insurance Element

    FHIR Specification

    • Short: Patient insurance information
    • Definition: Financial instruments for reimbursement for the health care products and services specified on the claim.
    • Comment: All insurance coverages for the patient which may be applicable for reimbursement, of the products and services listed in the claim, are typically provided in the claim to allow insurers to confirm the ordering of the insurance coverages relative to local 'coordination of benefit' rules. One coverage (and only one) with 'focal=true' is to be used in the adjudication of this claim. Coverages appearing before the focal Coverage in the list, and where 'subrogation=false', should provide a reference to the ClaimResponse containing the adjudication results of the prior claim.
    • Requirements: At least one insurer is required for a claim to be a claim.
    • FHIR Type: BackboneElement
    • Cardinality: 0..*
    • isModifier: false
    • isSummary: false
    error?: ClaimResponseErrorComponent[]

    ClaimResponse.error Element

    FHIR Specification

    • Short: Processing errors
    • Definition: Errors encountered during the processing of the adjudication.
    • Comment: If the request contains errors then an error element should be provided and no adjudication related sections (item, addItem, or payment) should be present.
    • Requirements: Need to communicate processing issues to the requestor.
    • FHIR Type: BackboneElement
    • Cardinality: 0..*
    • isModifier: false
    • isSummary: false

    Methods

    • Parse the provided ClaimResponse JSON to instantiate the ClaimResponse data model.

      Parameters

      • sourceJson: Value

        JSON representing FHIR ClaimResponse

      • OptionaloptSourceField: string

        Optional data source field (e.g. <complexTypeName>.<complexTypeFieldName>); defaults to ClaimResponse

      Returns undefined | ClaimResponse

      ClaimResponse data model or undefined for ClaimResponse

      JsonError if the provided JSON is not a valid JSON object

    • Assigns the provided Reference array value to the communicationRequest property.

      Parameters

      • value: undefined | Reference[]

        the communicationRequest array value

      Returns this

      this

      @ReferenceTargets('ClaimResponse.communicationRequest', ['CommunicationRequest',])

      InvalidTypeError for invalid data type or reference value

    • Assigns the provided value to the text property.

      Parameters

      Returns this

      this

    • Returns boolean

      true if the text property exists and has a value; false otherwise

    • Assigns the provided Resource array value to the contained property.

      Parameters

      • value: undefined | IResource[]

        the contained array value

      Returns this

      this

    • Returns boolean

      true if the contained property exists and has a value; false otherwise

    • Assigns the provided array of Extension values to the extension property.

      Parameters

      • extension: undefined | IExtension[]

        array of Extensions

      Returns this

      this

    • Determines if the extension property exists.

      Parameters

      • Optionalurl: string

        the url that identifies a specific Extension

      Returns boolean

      true if an Extension has the provided url; false otherwise

      If the url is provided, determines if an Extension having the provided url exists. If the url is not provided, determines if the extension property exists and has any values.

      AssertionError for invalid url

    • Adds the provided Extension to the extension property array.

      Parameters

      • extension: undefined | IExtension

        the Extension value to add to the extension property array

      Returns this

      this

    • Removes the Extension having the provided url from the extension property array.

      Parameters

      • url: string

        the url that identifies a specific Extension to remove

      Returns void

      AssertionError for invalid url

    • Determines if the modifierExtension property exists.

      Parameters

      • Optionalurl: string

        the url that identifies a specific Extension

      Returns boolean

      true if an Extension has the provided url

      If the url is provided, determines if an Extension having the provided url exists. If the url is not provided, determines if the modifierExtension property exists and has any values.

      AssertionError for invalid url

    • Assigns the provided PrimitiveType value to the id property.

      Parameters

      • element: undefined | IdType

        the id value

      Returns this

      this

    • Returns undefined | string

      the id property value as a primitive value

    • Assigns the provided primitive value to the id property.

      Parameters

      • value: undefined | string

        the id value

      Returns this

      this

      PrimitiveTypeError for invalid primitive types

    • Returns boolean

      true if the id property exists and has a value; false otherwise

    • Assigns the provided value to the meta property.

      Parameters

      • value: undefined | Meta

        the meta value

      Returns this

      this

    • Returns boolean

      true if the meta property exists and has a value; false otherwise

    • Assigns the provided primitive value to the implicitRules property.

      Parameters

      • value: undefined | string

        the implicitRules value

      Returns this

      this

      PrimitiveTypeError for invalid primitive types

    • Returns undefined | string

      the language property value as a primitive value

    • Assigns the provided primitive value to the language property.

      Parameters

      • value: undefined | string

        the language value

      Returns this

      this

      PrimitiveTypeError for invalid primitive types

    • Returns boolean

      true if the language property exists and has a value; false otherwise

    • Returns boolean

      true if the instance is a FHIR complex or primitive datatype; false otherwise

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