Claimresponse-example.xml

General Person Primary Coverage Example (id = "R3500")

<ClaimResponse xmlns="http://hl7.org/fhir">
 
 <id value="R3500"/>

 <text>
    <status value="generated"/>
    <div xmlns="http://www.w3.org/1999/xhtml">A human-readable rendering of the ClaimResponse</div>
 </text>

  <identifier>
    <system value="http://www.BenefitsInc.com/fhir/remittance"/>
    <value value="R3500"/>
  </identifier>

  <request>
    <reference value="http://www.BenefitsInc.com/fhir/oralhealthclaim/15476332402"/>
  </request>

  <created value="2014-08-16"/>

  <organization>
    <reference value="Organization/2"/>
  </organization>

  <requestOrganization>
    <reference value="Organization/1"/>
  </requestOrganization>

  <outcome value="complete"/>
 
  <disposition value="Claim settled as per contract."/>

  <payeeType>
     <system value="http://hl7.org/fhir/payeetype"/>
     <code value="provider"/>
  </payeeType>

 <!--   Adjudication details   -->
 
 <item>

   <sequenceLinkId value="1"/> 

   <adjudication>
     <code>
       <code value="eligible"/>
   </code>
   <amount>
       <value value="135.57"/>
    <system value="urn:iso:std:iso:4217"/>
    <code value="USD"/>
   </amount>
   </adjudication>

   <adjudication>
     <code>
       <code value="copay"/>
   </code>
   <amount>
      <value value="10.00"/>
    <system value="urn:iso:std:iso:4217"/>
    <code value="USD"/>
   </amount>  
   </adjudication>

   <adjudication>
     <code>
       <code value="eligpercent"/>
   </code>
   <value value="80.00"/>
   </adjudication>

   <adjudication>
     <code>
       <code value="benefit"/>
   </code>
   <amount>
        <value value="100.47"/>
    <system value="urn:iso:std:iso:4217"/>
    <code value="USD"/>
   </amount>  
   </adjudication>
   
 </item>

 <totalCost>
  <value value="135.57"/>
  <system value="urn:iso:std:iso:4217"/>
  <code value="USD"/>
 </totalCost>  
 
 <totalBenefit>
  <value value="100.47"/>
  <system value="urn:iso:std:iso:4217"/>
  <code value="USD"/>
 </totalBenefit>

 <!--   Payment details   -->
 
 <paymentDate value="2014-08-31"/>
 
 <paymentAmount>
  <value value="100.47"/>
  <system value="urn:iso:std:iso:4217"/>
  <code value="USD"/>
 </paymentAmount>  
 
 <paymentRef>
    <system value="http://www.BenefitsInc.com/fhir/paymentRef"/>
    <value value="201408-2-1569478"/>
 </paymentRef>  
 
</ClaimResponse>