FHIR © HL7.org  |  Server Home  |  Health Intersections FHIR Server v1.0.287  |  FHIR Version 4.0.0  | User: ANONYMOUS (Unknown)  

Resource "R3500" Version "1" (ClaimResponse)

Tags:

XML or JSON representation . provenance for this resource

A human-readable rendering of the ClaimResponse

{
  "resourceType" : "ClaimResponse",
  "id" : "R3500",
  "meta" : {
    "versionId" : "1",
    "lastUpdated" : "2018-12-14T02:01:34.161Z"
  },
  "text" : {
    "status" : "generated",
    "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\">A human-readable rendering of the ClaimResponse</div>"
  },
  "identifier" : [
    {
      "system" : "http://www.BenefitsInc.com/fhir/remittance",
      "value" : "R3500"
    }
  ],
  "status" : "active",
  "type" : {
    "coding" : [
      {
        "system" : "http://terminology.hl7.org/CodeSystem/claim-type",
        "code" : "oral"
      }
    ]
  },
  "subType" : {
    "coding" : [
      {
        "system" : "http://terminology.hl7.org/CodeSystem/ex-claimsubtype",
        "code" : "emergency"
      }
    ]
  },
  "use" : "claim",
  "patient" : {
    "reference" : "Patient/1"
  },
  "created" : "2014-08-16",
  "insurer" : {
    "identifier" : {
      "system" : "http://www.jurisdiction.org/insurers",
      "value" : "555123"
    }
  },
  "requestor" : {
    "reference" : "Organization/1"
  },
  "request" : {
    "reference" : "http://www.BenefitsInc.com/fhir/oralhealthclaim/15476332402"
  },
  "outcome" : "complete",
  "disposition" : "Claim settled as per contract.",
  "payeeType" : {
    "coding" : [
      {
        "system" : "http://terminology.hl7.org/CodeSystem/payeetype",
        "code" : "provider"
      }
    ]
  },
  "item" : [
    {
      "itemSequence" : 1,
      "adjudication" : [
        {
          "category" : {
            "coding" : [
              {
                "code" : "eligible"
              }
            ]
          },
          "amount" : {
            "value" : 135.57,
            "currency" : "USD"
          }
        },
        {
          "category" : {
            "coding" : [
              {
                "code" : "copay"
              }
            ]
          },
          "amount" : {
            "value" : 10.00,
            "currency" : "USD"
          }
        },
        {
          "category" : {
            "coding" : [
              {
                "code" : "eligpercent"
              }
            ]
          },
          "value" : 80.00
        },
        {
          "category" : {
            "coding" : [
              {
                "code" : "benefit"
              }
            ]
          },
          "reason" : {
            "coding" : [
              {
                "system" : "http://terminology.hl7.org/CodeSystem/adjudication-reason",
                "code" : "ar002",
                "display" : "Plan Limit Reached"
              }
            ]
          },
          "amount" : {
            "value" : 90.47,
            "currency" : "USD"
          }
        }
      ]
    }
  ],
  "total" : [
    {
      "category" : {
        "coding" : [
          {
            "code" : "submitted"
          }
        ]
      },
      "amount" : {
        "value" : 135.57,
        "currency" : "USD"
      }
    },
    {
      "category" : {
        "coding" : [
          {
            "code" : "benefit"
          }
        ]
      },
      "amount" : {
        "value" : 90.47,
        "currency" : "USD"
      }
    }
  ],
  "payment" : {
    "type" : {
      "coding" : [
        {
          "system" : "http://terminology.hl7.org/CodeSystem/ex-paymenttype",
          "code" : "complete"
        }
      ]
    },
    "date" : "2014-08-31",
    "amount" : {
      "value" : 100.47,
      "currency" : "USD"
    },
    "identifier" : {
      "system" : "http://www.BenefitsInc.com/fhir/paymentidentifier",
      "value" : "201408-2-1569478"
    }
  }
}