Release 5 Ballot
FinancialThis page is part of the FHIR Specification (v5.0.0-ballot: R5 Ballot - see ballot notes). The current version which supercedes this version is 5.0.0. For a full list of available versions, see the Directory of published versions 
. Page versions: R5 R4B R4
| Financial Management Work Group | Maturity Level: N/A | Standards Status: Informative | Compartments: Patient, Practitioner |
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A ClaimResponse demonstrating Payor service code substitutions
@prefix fhir: <http://hl7.org/fhir/> .
@prefix owl: <http://www.w3.org/2002/07/owl#> .
@prefix rdfs: <http://www.w3.org/2000/01/rdf-schema#> .
@prefix xsd: <http://www.w3.org/2001/XMLSchema#> .
# - resource -------------------------------------------------------------------
[a fhir:ClaimResponse;
fhir:nodeRole fhir:treeRoot;
fhir:Resource.id [ fhir:value "R3503"];
fhir:DomainResource.text [
fhir:Narrative.status [ fhir:value "generated" ];
fhir:Narrative.div "<div xmlns=\"http://www.w3.org/1999/xhtml\">A human-readable rendering of the ClaimResponse to Claim Oral Average with additional items</div>"
];
fhir:ClaimResponse.identifier [
fhir:index 0;
fhir:Identifier.system [ fhir:value "http://www.BenefitsInc.com/fhir/remittance" ];
fhir:Identifier.value [ fhir:value "R3503" ]
];
fhir:ClaimResponse.status [ fhir:value "active"];
fhir:ClaimResponse.type [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/claim-type" ];
fhir:Coding.code [ fhir:value "oral" ]
]
];
fhir:ClaimResponse.use [ fhir:value "claim"];
fhir:ClaimResponse.patient [
fhir:Reference.reference [ fhir:value "Patient/1" ]
];
fhir:ClaimResponse.created [ fhir:value "2014-08-16"^^xsd:date];
fhir:ClaimResponse.insurer [
fhir:Reference.identifier [
fhir:Identifier.system [ fhir:value "http://www.jurisdiction.org/insurers" ];
fhir:Identifier.value [ fhir:value "555123" ]
]
];
fhir:ClaimResponse.requestor [
fhir:Reference.reference [ fhir:value "Organization/1" ]
];
fhir:ClaimResponse.request [
fhir:Reference.identifier [
fhir:Identifier.system [ fhir:value "http://happyvalley.com/claim" ];
fhir:Identifier.value [ fhir:value "12346" ]
]
];
fhir:ClaimResponse.outcome [ fhir:value "complete"];
fhir:ClaimResponse.disposition [ fhir:value "Claim settled as per contract."];
fhir:ClaimResponse.payeeType [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/payeetype" ];
fhir:Coding.code [ fhir:value "provider" ]
]
];
fhir:ClaimResponse.item [
fhir:index 0;
fhir:ClaimResponse.item.itemSequence [ fhir:value "1"^^xsd:positiveInteger ];
fhir:ClaimResponse.item.adjudication [
fhir:index 0;
fhir:ClaimResponse.item.adjudication.category [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.code [ fhir:value "eligible" ]
]
];
fhir:ClaimResponse.item.adjudication.amount [
fhir:Money.value [ fhir:value "0.00"^^xsd:decimal ];
fhir:Money.currency [ fhir:value "USD" ]
]
], [
fhir:index 1;
fhir:ClaimResponse.item.adjudication.category [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.code [ fhir:value "benefit" ]
]
];
fhir:ClaimResponse.item.adjudication.amount [
fhir:Money.value [ fhir:value "0.00"^^xsd:decimal ];
fhir:Money.currency [ fhir:value "USD" ]
]
]
], [
fhir:index 1;
fhir:ClaimResponse.item.itemSequence [ fhir:value "2"^^xsd:positiveInteger ];
fhir:ClaimResponse.item.adjudication [
fhir:index 0;
fhir:ClaimResponse.item.adjudication.category [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.code [ fhir:value "eligible" ]
]
];
fhir:ClaimResponse.item.adjudication.amount [
fhir:Money.value [ fhir:value "105.00"^^xsd:decimal ];
fhir:Money.currency [ fhir:value "USD" ]
]
], [
fhir:index 1;
fhir:ClaimResponse.item.adjudication.category [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.code [ fhir:value "eligpercent" ]
]
];
fhir:ClaimResponse.item.adjudication.value [ fhir:value "80.00"^^xsd:decimal ]
], [
fhir:index 2;
fhir:ClaimResponse.item.adjudication.category [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.code [ fhir:value "benefit" ]
]
];
fhir:ClaimResponse.item.adjudication.amount [
fhir:Money.value [ fhir:value "84.00"^^xsd:decimal ];
fhir:Money.currency [ fhir:value "USD" ]
]
]
], [
fhir:index 2;
fhir:ClaimResponse.item.itemSequence [ fhir:value "3"^^xsd:positiveInteger ];
fhir:ClaimResponse.item.adjudication [
fhir:index 0;
fhir:ClaimResponse.item.adjudication.category [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.code [ fhir:value "eligible" ]
]
];
fhir:ClaimResponse.item.adjudication.amount [
fhir:Money.value [ fhir:value "750.00"^^xsd:decimal ];
fhir:Money.currency [ fhir:value "USD" ]
]
], [
fhir:index 1;
fhir:ClaimResponse.item.adjudication.category [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.code [ fhir:value "eligpercent" ]
]
];
fhir:ClaimResponse.item.adjudication.value [ fhir:value "80.00"^^xsd:decimal ]
], [
fhir:index 2;
fhir:ClaimResponse.item.adjudication.category [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.code [ fhir:value "benefit" ]
]
];
fhir:ClaimResponse.item.adjudication.amount [
fhir:Money.value [ fhir:value "600.00"^^xsd:decimal ];
fhir:Money.currency [ fhir:value "USD" ]
]
];
fhir:ClaimResponse.item.detail [
fhir:index 0;
fhir:ClaimResponse.item.detail.detailSequence [ fhir:value "1"^^xsd:positiveInteger ];
fhir:ClaimResponse.item.detail.adjudication [
fhir:index 0;
fhir:ClaimResponse.item.adjudication.category [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.code [ fhir:value "eligible" ]
]
];
fhir:ClaimResponse.item.adjudication.amount [
fhir:Money.value [ fhir:value "750.00"^^xsd:decimal ];
fhir:Money.currency [ fhir:value "USD" ]
]
], [
fhir:index 1;
fhir:ClaimResponse.item.adjudication.category [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.code [ fhir:value "eligpercent" ]
]
];
fhir:ClaimResponse.item.adjudication.value [ fhir:value "80.00"^^xsd:decimal ]
], [
fhir:index 2;
fhir:ClaimResponse.item.adjudication.category [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.code [ fhir:value "benefit" ]
]
];
fhir:ClaimResponse.item.adjudication.amount [
fhir:Money.value [ fhir:value "600.00"^^xsd:decimal ];
fhir:Money.currency [ fhir:value "USD" ]
]
]
], [
fhir:index 1;
fhir:ClaimResponse.item.detail.detailSequence [ fhir:value "2"^^xsd:positiveInteger ];
fhir:ClaimResponse.item.detail.adjudication [
fhir:index 0;
fhir:ClaimResponse.item.adjudication.category [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.code [ fhir:value "eligible" ]
]
];
fhir:ClaimResponse.item.adjudication.amount [
fhir:Money.value [ fhir:value "0.00"^^xsd:decimal ];
fhir:Money.currency [ fhir:value "USD" ]
]
], [
fhir:index 1;
fhir:ClaimResponse.item.adjudication.category [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.code [ fhir:value "benefit" ]
]
];
fhir:ClaimResponse.item.adjudication.amount [
fhir:Money.value [ fhir:value "0.00"^^xsd:decimal ];
fhir:Money.currency [ fhir:value "USD" ]
]
]
]
];
fhir:ClaimResponse.addItem [
fhir:index 0;
fhir:ClaimResponse.addItem.itemSequence [
fhir:value "1"^^xsd:positiveInteger;
fhir:index 0
];
fhir:ClaimResponse.addItem.productOrService [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://example.org/fhir/oralservicecodes" ];
fhir:Coding.code [ fhir:value "1101" ]
]
];
fhir:ClaimResponse.addItem.modifier [
fhir:index 0;
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://example.org/fhir/modifiers" ];
fhir:Coding.code [ fhir:value "x" ];
fhir:Coding.display [ fhir:value "None" ]
]
];
fhir:ClaimResponse.addItem.net [
fhir:Money.value [ fhir:value "135.57"^^xsd:decimal ];
fhir:Money.currency [ fhir:value "USD" ]
];
fhir:ClaimResponse.addItem.noteNumber [
fhir:value "101"^^xsd:positiveInteger;
fhir:index 0
];
fhir:ClaimResponse.addItem.adjudication [
fhir:index 0;
fhir:ClaimResponse.item.adjudication.category [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.code [ fhir:value "eligible" ]
]
];
fhir:ClaimResponse.item.adjudication.amount [
fhir:Money.value [ fhir:value "100.00"^^xsd:decimal ];
fhir:Money.currency [ fhir:value "USD" ]
]
], [
fhir:index 1;
fhir:ClaimResponse.item.adjudication.category [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.code [ fhir:value "copay" ]
]
];
fhir:ClaimResponse.item.adjudication.amount [
fhir:Money.value [ fhir:value "10.00"^^xsd:decimal ];
fhir:Money.currency [ fhir:value "USD" ]
]
], [
fhir:index 2;
fhir:ClaimResponse.item.adjudication.category [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.code [ fhir:value "eligpercent" ]
]
];
fhir:ClaimResponse.item.adjudication.value [ fhir:value "80.00"^^xsd:decimal ]
], [
fhir:index 3;
fhir:ClaimResponse.item.adjudication.category [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.code [ fhir:value "benefit" ]
]
];
fhir:ClaimResponse.item.adjudication.reason [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/adjudication-reason" ];
fhir:Coding.code [ fhir:value "ar002" ];
fhir:Coding.display [ fhir:value "Plan Limit Reached" ]
]
];
fhir:ClaimResponse.item.adjudication.amount [
fhir:Money.value [ fhir:value "72.00"^^xsd:decimal ];
fhir:Money.currency [ fhir:value "USD" ]
]
]
], [
fhir:index 1;
fhir:ClaimResponse.addItem.itemSequence [
fhir:value "1"^^xsd:positiveInteger;
fhir:index 0
];
fhir:ClaimResponse.addItem.productOrService [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://example.org/fhir/oralservicecodes" ];
fhir:Coding.code [ fhir:value "2141" ];
fhir:Coding.display [ fhir:value "Radiograph, bytewing" ]
]
];
fhir:ClaimResponse.addItem.net [
fhir:Money.value [ fhir:value "35.57"^^xsd:decimal ];
fhir:Money.currency [ fhir:value "USD" ]
];
fhir:ClaimResponse.addItem.adjudication [
fhir:index 0;
fhir:ClaimResponse.item.adjudication.category [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.code [ fhir:value "eligible" ]
]
];
fhir:ClaimResponse.item.adjudication.amount [
fhir:Money.value [ fhir:value "35.57"^^xsd:decimal ];
fhir:Money.currency [ fhir:value "USD" ]
]
], [
fhir:index 1;
fhir:ClaimResponse.item.adjudication.category [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.code [ fhir:value "eligpercent" ]
]
];
fhir:ClaimResponse.item.adjudication.value [ fhir:value "80.00"^^xsd:decimal ]
], [
fhir:index 2;
fhir:ClaimResponse.item.adjudication.category [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.code [ fhir:value "benefit" ]
]
];
fhir:ClaimResponse.item.adjudication.amount [
fhir:Money.value [ fhir:value "28.47"^^xsd:decimal ];
fhir:Money.currency [ fhir:value "USD" ]
]
]
], [
fhir:index 2;
fhir:ClaimResponse.addItem.itemSequence [
fhir:value "3"^^xsd:positiveInteger;
fhir:index 0
];
fhir:ClaimResponse.addItem.detailSequence [
fhir:value "2"^^xsd:positiveInteger;
fhir:index 0
];
fhir:ClaimResponse.addItem.productOrService [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://example.org/fhir/oralservicecodes" ];
fhir:Coding.code [ fhir:value "expense" ]
]
];
fhir:ClaimResponse.addItem.modifier [
fhir:index 0;
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://example.org/fhir/modifiers" ];
fhir:Coding.code [ fhir:value "x" ];
fhir:Coding.display [ fhir:value "None" ]
]
];
fhir:ClaimResponse.addItem.net [
fhir:Money.value [ fhir:value "350.00"^^xsd:decimal ];
fhir:Money.currency [ fhir:value "USD" ]
];
fhir:ClaimResponse.addItem.noteNumber [
fhir:value "101"^^xsd:positiveInteger;
fhir:index 0
];
fhir:ClaimResponse.addItem.adjudication [
fhir:index 0;
fhir:ClaimResponse.item.adjudication.category [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.code [ fhir:value "eligible" ]
]
];
fhir:ClaimResponse.item.adjudication.amount [
fhir:Money.value [ fhir:value "350.00"^^xsd:decimal ];
fhir:Money.currency [ fhir:value "USD" ]
]
], [
fhir:index 1;
fhir:ClaimResponse.item.adjudication.category [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.code [ fhir:value "eligpercent" ]
]
];
fhir:ClaimResponse.item.adjudication.value [ fhir:value "80.00"^^xsd:decimal ]
], [
fhir:index 2;
fhir:ClaimResponse.item.adjudication.category [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.code [ fhir:value "benefit" ]
]
];
fhir:ClaimResponse.item.adjudication.amount [
fhir:Money.value [ fhir:value "270.00"^^xsd:decimal ];
fhir:Money.currency [ fhir:value "USD" ]
]
]
];
fhir:ClaimResponse.total [
fhir:index 0;
fhir:ClaimResponse.total.category [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.code [ fhir:value "submitted" ]
]
];
fhir:ClaimResponse.total.amount [
fhir:Money.value [ fhir:value "1340.57"^^xsd:decimal ];
fhir:Money.currency [ fhir:value "USD" ]
]
], [
fhir:index 1;
fhir:ClaimResponse.total.category [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.code [ fhir:value "benefit" ]
]
];
fhir:ClaimResponse.total.amount [
fhir:Money.value [ fhir:value "1054.47"^^xsd:decimal ];
fhir:Money.currency [ fhir:value "USD" ]
]
];
fhir:ClaimResponse.payment [
fhir:ClaimResponse.payment.type [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/ex-paymenttype" ];
fhir:Coding.code [ fhir:value "complete" ]
]
];
fhir:ClaimResponse.payment.date [ fhir:value "2014-08-31"^^xsd:date ];
fhir:ClaimResponse.payment.amount [
fhir:Money.value [ fhir:value "100.47"^^xsd:decimal ];
fhir:Money.currency [ fhir:value "USD" ]
];
fhir:ClaimResponse.payment.identifier [
fhir:Identifier.system [ fhir:value "http://www.BenefitsInc.com/fhir/paymentidentifier" ];
fhir:Identifier.value [ fhir:value "201408-2-15507" ]
]
];
fhir:ClaimResponse.processNote [
fhir:index 0;
fhir:ClaimResponse.processNote.number [ fhir:value "101"^^xsd:positiveInteger ];
fhir:ClaimResponse.processNote.type [ fhir:value "print" ];
fhir:ClaimResponse.processNote.text [ fhir:value "Package codes are not permitted. Codes replaced by Insurer." ];
fhir:ClaimResponse.processNote.language [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "urn:ietf:bcp:47" ];
fhir:Coding.code [ fhir:value "en-CA" ]
]
]
]] .
# - ontology header ------------------------------------------------------------
[a owl:Ontology;
owl:imports fhir:fhir.ttl] .
# -------------------------------------------------------------------------------------
Usage note: every effort has been made to ensure that the examples are correct and useful, but they are not a normative part of the specification.
FHIR ®© HL7.org 2011+. FHIR R5 Ballot hl7.fhir.core#5.0.0-ballot generated on Sat, Sep 10, 2022 05:01+1000.
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