Claim response
The payer's adjudication of a submitted claim, on /v1/claim/on_submit. The same bundle carries an acknowledgement, an approval, a query and a rejection.
Sent on /v1/claim/on_submit.
The bundle
| # | Resource | Profile |
|---|---|---|
| 1 | ClaimResponse | none declared; NRCeS ClaimResponse |
| 2 | Patient | none declared; NRCeS Patient |
| 3 | Organization (pay) | none declared; NRCeS Organization |
| 4 | Organization (prov) | none declared; NRCeS Organization |
| 5 | Coverage | none declared; NRCeS Coverage |
Elements
1. ClaimResponse
NRCeS profile: ClaimResponse.
| Element | Example |
|---|---|
identifier[] | system <participant-defined>, value NM-26-0SE00002L |
identifier[].type.coding[] | CLN Claim number in https://nrces.in/ndhm/fhir/r4/CodeSystem/ndhm-identifier-type-code |
status | active |
use | claim |
patient | reference <participant-defined> |
created | 2026-09-10T23:53:32+05:30 |
insurer | reference <participant-defined> |
requestor | reference <participant-defined> |
outcome | complete |
disposition | Reprocessed and approved. |
payeeType.coding[] | provider Provider in http://terminology.hl7.org/CodeSystem/payeetype |
item[] | id Item/LI-558aa12a, itemSequence 1 |
item[].adjudication[].category.coding[] | submitted Submitted Amount in https://hl7.org/fhir/R4/valueset-adjudication.html |
eligible Eligible Amount in https://hl7.org/fhir/R4/valueset-adjudication.html | |
reason Reason for Adjudication in https://hl7.org/fhir/R4/valueset-adjudication.html | |
| and 1 more | |
item[].adjudication[].amount | value 150000 |
item[].adjudication[].reason.coding[] | display Reprocessed and approved. |
Approved Approved | |
adjudication[].category.coding[] | status Status |
adjudication[].reason.coding[] | approved Approved |
total[].category.coding[] | benefit Benefit Amount in https://hl7.org/fhir/R4/valueset-adjudication.html |
submitted Submitted Amount in https://hl7.org/fhir/R4/valueset-adjudication.html | |
eligible Eligible Amount | |
total[].amount | value 150000 |
total[] | id MRAV1985001/SANDBOX-DEFAULT-01 |
2. Patient
NRCeS profile: Patient.
| Element | Example |
|---|---|
identifier[] | system <participant-defined>, value MRAV1985001 |
identifier[].type.coding[] | MB Member Number in http://terminology.hl7.org/CodeSystem/v2-0203 |
name[] | family Kumar, given Ravi, text Ravi Kumar |
gender | male |
birthDate | 1985-06-15 |
3. Organization (pay)
NRCeS profile: Organization.
| Element | Example |
|---|---|
active | true |
identifier[] | system https://facility.abdm.gov.in, value 1000004805 |
identifier[].type.coding[] | NIIP National Insurance Payor Identifier (Payor) in http://terminology.hl7.org/CodeSystem/v2-0203 |
type[].coding[] | pay Payer in http://terminology.hl7.org/CodeSystem/organization-type |
name | Sandbox Payer |
4. Organization (prov)
NRCeS profile: Organization.
| Element | Example |
|---|---|
active | true |
identifier[] | system https://facility.abdm.gov.in, value IN1910000151 |
identifier[].type.coding[] | NPI National provider identifier in http://terminology.hl7.org/CodeSystem/v2-0203 |
type[].coding[] | prov Healthcare Provider in http://terminology.hl7.org/CodeSystem/organization-type |
name | KyroCare Multispeciality Hospital |
5. Coverage
NRCeS profile: Coverage.
| Element | Example |
|---|---|
identifier[] | system <participant-defined>, value SANDBOX-DEFAULT-01 |
identifier[].type.coding[] | NH National Health Plan Identifier in http://terminology.hl7.org/CodeSystem/v2-0203 |
status | active |
type.coding[] | HIP health insurance plan policy in http://terminology.hl7.org/CodeSystem/v3-ActCode |
beneficiary | reference <participant-defined> |
period | start 2026-01-01T00:00:00+05:30, end 2026-12-31T00:00:00+05:30 |
payor[] | reference <participant-defined> |
class[] | id POL7UMU002, value SANDBOX-DEFAULT-01 |
class[].type.coding[] | XV Health Plan Identifier in http://terminology.hl7.org/CodeSystem/v2-0203 |
The answers
The same bundle, told apart by the workflow code, outcome and the claim-level adjudication reason.
| Variant | Workflow | outcome | reason |
|---|---|---|---|
| Acknowledged | 25 | queued | submitted Submitted |
| Approved | 26 | complete | approved Approved |
| Queried | 27 | partial | queried Queried |
| Rejected | 291 | error | rejected Rejected |
Rules
1. partial is two things
An acknowledgement and a query are both partial. Read the claim-level reason, then disposition, then the totals.
2. Deductions
Item-level deductible adjudications carry the amount and the reason. Sum them before reporting an approved figure.
3. Joining
Join the response to the claim by identifier.value.
4. Settlement is separate
An approval closes adjudication, not the money. The claim closes on the payment notice.
5. Submitted amounts
Do not reconcile your submitted amount against the payer's submitted total; it comes from the payer's own record.
PMJAY
The generic bundle above is what every payer takes, IRDAI-regulated insurers and TPAs included. PMJAY takes it with the changes and requirements below.
What changes in the bundle
PMJAY sends this exchange in the generic shape.
What PMJAY specifies
total[]adds ataxline besidebenefitandsubmitted.- The adjudication reason carries the desk's audit trail, with mixed date formats. Display it; never parse a timestamp from it.
- A benefit of 0 on a query means undetermined, not refused.
Use cases, APIs and data elements
C7 Respond to claim (payer)
The adjudicated claim, item by item, with any deduction and its reason. The acknowledgement on 25 travels as response.partial with the payer's case number. Under PMJAY a query is this ClaimResponse on 27, answered by a fresh submit on 161.
| API | /v1/claim/on_submit apis/05-claim/v1-claim-on-submit.bru |
| Callback | /v1/claim/submit apis/05-claim/v1-claim-submit.bru |
| Workflow | 25 received, 26 approved, 27 queried, 28 in process, 29 forwarded, 291 denied |
| Carries JWE | yes |
| Focal resource | ClaimResponse |
Request headers
| Header | Example value |
|---|---|
x-hcx-sender_code | 1518@hcx |
x-hcx-recipient_code | 1000004446@hcx |
x-hcx-api_call_id | {{$guid}} |
x-hcx-request_id | {{$guid}} |
x-hcx-correlation_id | {{$guid}} |
x-hcx-workflow_id | 26 |
x-hcx-timestamp | {{$isoTimestamp}} |
x-hcx-status | response.complete |
x-hcx-ben-abha-id | 91711234567890 |
x-hcx-debug_flag | INFO |
Workflow codes
| Code | Name | Authored by | x-hcx-status | Means |
|---|---|---|---|---|
25 | Claim Request Received | payer | response.partial, response.error | Final claim received by payer |
26 | Claim Request Approved | payer | response.complete | Final claim approved |
27 | Claim Request Queried | payer | request.initiated, response.partial/complete | Final claim queried - payer needs additional documents; under PMJAY answer with 161 |
28 | Claim Request In Process | payer | response.partial | Final claim is being processed by payer |
29 | Claim Forwarded | payer | response.partial | Claim forwarded to another processing entity |
291 | Claim Doc Deny | status sheet only | response.complete |
Data elements
| Element | Label | Group | Type | Card. | FHIR path | Example | Notes |
|---|---|---|---|---|---|---|---|
outcome | Claim Outcome | Adjudication | code | 1..1 | ClaimResponse.outcome | complete | |
approvedBenefit | Approved Claim Amount | Financials | decimal | 1..1 | ClaimResponse.total[category=benefit].amount.value | 15500.00 | |
copayAmount | Beneficiary Co-payment | Financials | decimal | 0..1 | ClaimResponse.total[category=copay].amount.value | 0.00 | |
deductionReason | Deduction Justification | Adjudication | string | 0..1 | ClaimResponse.item[].adjudication[category=deduction].reason.coding[0].display | Non-medical consumables deducted |
NRCeS profiles: ClaimResponse.