ClaimResponse resource (FHIR R4)

ClaimResponse is the FHIR R4 resource for this resource provides the adjudication details from the processing of a Claim resource.

Example

{
  "resourceType": "ClaimResponse",
  "id": "claimresponse-bd3ebadd927cb351bdc84461eda4f947",
  "status": "active",
  "type": {
    "coding": [
      {
        "system": "http://terminology.hl7.org/CodeSystem/claim-type",
        "code": "professional",
        "display": "Professional"
      }
    ]
  },
  "use": "claim",
  "patient": {
    "reference": "Patient/patient-L46A6EIB9J"
  },
  "created": "2026-07-01",
  "insurer": {
    "display": "Synthetic Mutual Health Plan"
  },
  "request": {
    "reference": "Claim/claim-297b3db9950d1643d86ba346ea22719e"
  },
  "outcome": "complete",
  "disposition": "Claim adjudicated per the subscriber's plan benefit schedule.",
  "total": [
    {
      "category": {
        "coding": [
          {
            "system": "http://terminology.hl7.org/CodeSystem/adjudication",
            "code": "submitted",
            "display": "Submitted Amount"
          }
        ]
      },
      "amount": {
        "value": 70,
        "currency": "USD"
      }
    },
    {
      "category": {
        "coding": [
          {
            "system": "http://terminology.hl7.org/CodeSystem/adjudication",
            "code": "benefit",
            "display": "Benefit Amount"
          }
        ]
      },
      "amount": {
        "value": 56,
        "currency": "USD"
      }
    }
  ]
}

Generated by the Pidgeon engine: pidgeon generate ClaimResponse --seed 20260722.

Validation context

• strict pidgeon validate grades a ClaimResponse instance against the base R4 structure definition: missing required elements raise REQUIRED_FIELD_MISSING and cardinality violations raise CARDINALITY_MIN or CARDINALITY_MAX.(REQUIRED_FIELD_MISSING)
• strict Profile validation grades the same instance against an installed IG profile: profile cardinality findings carry FHIR-PROFILE-CARDINALITY and terminology binding findings carry FHIR-PROFILE-BINDING.(FHIR-PROFILE-CARDINALITY)