Claimresponse-example-vision-3tier.json

Primary insurance response to a 3Tier Vision Claim

{
  "resourceType": "ClaimResponse",
  "id": "R3502",
  "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"
          }
        ]
      }
    }
  ]
}