Claimresponse-example.json

General Person Primary Coverage Example

{
  "resourceType": "ClaimResponse",
  "id": "R3500",
  "text": {
    "status": "generated",
    "div": "<div>A human-readable rendering of the ClaimResponse</div>"
  },
  "identifier": [
    {
      "system": "http://www.BenefitsInc.com/fhir/remittance",
      "value": "R3500"
    }
  ],
  "requestReference": {
    "reference": "http://www.BenefitsInc.com/fhir/oralhealthclaim/15476332402"
  },
  "created": "2014-08-16",
  "organizationIdentifier": {
    "fhir_comments": [
      "  \n  <OrganizationReference>\n    <reference value=\"Organization/2\"/>\n  </OrganizationReference>\n  "
    ],
    "system": "http://www.jurisdiction.org/insurers",
    "value": "555123"
  },
  "outcome": "complete",
  "_outcome": {
    "fhir_comments": [
      "  <requestOrganizationReference>\n    <reference value=\"Organization/1\"/>\n  </requestOrganizationReference>\n "
    ]
  },
  "disposition": "Claim settled as per contract.",
  "payeeType": {
    "system": "http://hl7.org/fhir/payeetype",
    "code": "provider"
  },
  "item": [
    {
      "fhir_comments": [
        "  Adjudication details  "
      ],
      "sequenceLinkId": 1,
      "adjudication": [
        {
          "category": {
            "code": "eligible"
          },
          "amount": {
            "value": 135.57,
            "system": "urn:iso:std:iso:4217",
            "code": "USD"
          }
        },
        {
          "category": {
            "code": "copay"
          },
          "amount": {
            "value": 10.00,
            "system": "urn:iso:std:iso:4217",
            "code": "USD"
          }
        },
        {
          "category": {
            "code": "eligpercent"
          },
          "value": 80.00
        },
        {
          "category": {
            "code": "benefit"
          },
          "amount": {
            "value": 100.47,
            "system": "urn:iso:std:iso:4217",
            "code": "USD"
          }
        }
      ]
    }
  ],
  "totalCost": {
    "value": 135.57,
    "system": "urn:iso:std:iso:4217",
    "code": "USD"
  },
  "totalBenefit": {
    "value": 100.47,
    "system": "urn:iso:std:iso:4217",
    "code": "USD"
  },
  "paymentDate": "2014-08-31",
  "_paymentDate": {
    "fhir_comments": [
      "  Payment details  "
    ]
  },
  "paymentAmount": {
    "value": 100.47,
    "system": "urn:iso:std:iso:4217",
    "code": "USD"
  },
  "paymentRef": {
    "system": "http://www.BenefitsInc.com/fhir/paymentRef",
    "value": "201408-2-1569478"
  }
}