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Resource "R3502" Version "1" (ClaimResponse)

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XML or JSON representation . provenance for this resource

A human-readable rendering of the ClaimResponse

{
  "resourceType" : "ClaimResponse",
  "id" : "R3502",
  "meta" : {
    "versionId" : "1",
    "lastUpdated" : "2018-12-14T02:01:34.223Z"
  },
  "text" : {
    "status" : "generated",
    "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\">A human-readable rendering of the ClaimResponse</div>"
  },
  "identifier" : [
    {
      "system" : "http://thebenefitcompany.com/claimresponse",
      "value" : "CR6532875367"
    }
  ],
  "status" : "active",
  "type" : {
    "coding" : [
      {
        "system" : "http://terminology.hl7.org/CodeSystem/claim-type",
        "code" : "vision"
      }
    ]
  },
  "use" : "claim",
  "patient" : {
    "reference" : "Patient/1"
  },
  "created" : "2014-08-16",
  "insurer" : {
    "reference" : "Organization/2"
  },
  "requestor" : {
    "reference" : "Organization/1"
  },
  "request" : {
    "identifier" : {
      "system" : "http://happysight.com/claim",
      "value" : "6612346"
    }
  },
  "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" : 235.40,
            "currency" : "USD"
          }
        },
        {
          "category" : {
            "coding" : [
              {
                "code" : "copay"
              }
            ]
          },
          "amount" : {
            "value" : 20.00,
            "currency" : "USD"
          }
        },
        {
          "category" : {
            "coding" : [
              {
                "code" : "eligpercent"
              }
            ]
          },
          "value" : 80.00
        },
        {
          "category" : {
            "coding" : [
              {
                "code" : "benefit"
              }
            ]
          },
          "amount" : {
            "value" : 172.32,
            "currency" : "USD"
          }
        }
      ],
      "detail" : [
        {
          "detailSequence" : 1,
          "noteNumber" : [
            "1"
          ],
          "adjudication" : [
            {
              "category" : {
                "coding" : [
                  {
                    "code" : "eligible"
                  }
                ]
              },
              "amount" : {
                "value" : 100.00,
                "currency" : "USD"
              }
            },
            {
              "category" : {
                "coding" : [
                  {
                    "code" : "copay"
                  }
                ]
              },
              "amount" : {
                "value" : 20.00,
                "currency" : "USD"
              }
            },
            {
              "category" : {
                "coding" : [
                  {
                    "code" : "eligpercent"
                  }
                ]
              },
              "value" : 80.00
            },
            {
              "category" : {
                "coding" : [
                  {
                    "code" : "benefit"
                  }
                ]
              },
              "amount" : {
                "value" : 80.00,
                "currency" : "USD"
              }
            }
          ]
        },
        {
          "detailSequence" : 2,
          "noteNumber" : [
            "1"
          ],
          "adjudication" : [
            {
              "category" : {
                "coding" : [
                  {
                    "code" : "eligible"
                  }
                ]
              },
              "amount" : {
                "value" : 110.00,
                "currency" : "USD"
              }
            },
            {
              "category" : {
                "coding" : [
                  {
                    "code" : "eligpercent"
                  }
                ]
              },
              "value" : 80.00
            },
            {
              "category" : {
                "coding" : [
                  {
                    "code" : "benefit"
                  }
                ]
              },
              "amount" : {
                "value" : 88.00,
                "currency" : "USD"
              }
            }
          ],
          "subDetail" : [
            {
              "subDetailSequence" : 1,
              "noteNumber" : [
                "1"
              ],
              "adjudication" : [
                {
                  "category" : {
                    "coding" : [
                      {
                        "code" : "eligible"
                      }
                    ]
                  },
                  "amount" : {
                    "value" : 60.00,
                    "currency" : "USD"
                  }
                },
                {
                  "category" : {
                    "coding" : [
                      {
                        "code" : "eligpercent"
                      }
                    ]
                  },
                  "value" : 80.00
                },
                {
                  "category" : {
                    "coding" : [
                      {
                        "code" : "benefit"
                      }
                    ]
                  },
                  "amount" : {
                    "value" : 48.00,
                    "currency" : "USD"
                  }
                }
              ]
            },
            {
              "subDetailSequence" : 2,
              "adjudication" : [
                {
                  "category" : {
                    "coding" : [
                      {
                        "code" : "eligible"
                      }
                    ]
                  },
                  "amount" : {
                    "value" : 30.00,
                    "currency" : "USD"
                  }
                },
                {
                  "category" : {
                    "coding" : [
                      {
                        "code" : "eligpercent"
                      }
                    ]
                  },
                  "value" : 80.00
                },
                {
                  "category" : {
                    "coding" : [
                      {
                        "code" : "benefit"
                      }
                    ]
                  },
                  "amount" : {
                    "value" : 24.00,
                    "currency" : "USD"
                  }
                }
              ]
            },
            {
              "subDetailSequence" : 3,
              "noteNumber" : [
                "1"
              ],
              "adjudication" : [
                {
                  "category" : {
                    "coding" : [
                      {
                        "code" : "eligible"
                      }
                    ]
                  },
                  "amount" : {
                    "value" : 10.00,
                    "currency" : "USD"
                  }
                },
                {
                  "category" : {
                    "coding" : [
                      {
                        "code" : "eligpercent"
                      }
                    ]
                  },
                  "value" : 80.00
                },
                {
                  "category" : {
                    "coding" : [
                      {
                        "code" : "benefit"
                      }
                    ]
                  },
                  "amount" : {
                    "value" : 8.00,
                    "currency" : "USD"
                  }
                }
              ]
            }
          ]
        },
        {
          "detailSequence" : 3,
          "noteNumber" : [
            "1"
          ],
          "adjudication" : [
            {
              "category" : {
                "coding" : [
                  {
                    "code" : "eligible"
                  }
                ]
              },
              "amount" : {
                "value" : 200.00,
                "currency" : "USD"
              }
            },
            {
              "category" : {
                "coding" : [
                  {
                    "code" : "eligpercent"
                  }
                ]
              },
              "value" : 80.00
            },
            {
              "category" : {
                "coding" : [
                  {
                    "code" : "benefit"
                  }
                ]
              },
              "amount" : {
                "value" : 14.00,
                "currency" : "USD"
              }
            }
          ]
        }
      ]
    }
  ],
  "total" : [
    {
      "category" : {
        "coding" : [
          {
            "code" : "submitted"
          }
        ]
      },
      "amount" : {
        "value" : 235.40,
        "currency" : "USD"
      }
    },
    {
      "category" : {
        "coding" : [
          {
            "code" : "benefit"
          }
        ]
      },
      "amount" : {
        "value" : 182.00,
        "currency" : "USD"
      }
    }
  ],
  "payment" : {
    "type" : {
      "coding" : [
        {
          "system" : "http://terminology.hl7.org/CodeSystem/ex-paymenttype",
          "code" : "complete"
        }
      ]
    },
    "adjustment" : {
      "value" : 75.00,
      "currency" : "USD"
    },
    "adjustmentReason" : {
      "coding" : [
        {
          "system" : "http://terminology.hl7.org/CodeSystem/payment-adjustment-reason",
          "code" : "a002",
          "display" : "Prior Overpayment"
        }
      ]
    },
    "date" : "2014-08-16",
    "amount" : {
      "value" : 107.00,
      "currency" : "USD"
    },
    "identifier" : {
      "system" : "http://thebenefitcompany.com/paymentidentifier",
      "value" : "201416-123456"
    }
  },
  "processNote" : [
    {
      "number" : 1,
      "type" : "display",
      "text" : "After hours surcharge declined",
      "language" : {
        "coding" : [
          {
            "system" : "urn:ietf:bcp:47",
            "code" : "en-CA"
          }
        ]
      }
    }
  ]
}