A ClaimResponse demonstrating Payor service code substitutions

{
  "resourceType" : "ClaimResponse",
  "id" : "R3503",
  "text" : {
    "status" : "generated",
    "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\">A human-readable rendering of the ClaimResponse to Claim Oral Average with additional items</div>"
  },
  "identifier" : [{
    "system" : "http://www.BenefitsInc.com/fhir/remittance",
    "value" : "R3503"
  }],
  "status" : "active",
  "type" : {
    "coding" : [{
      "system" : "http://terminology.hl7.org/CodeSystem/claim-type",
      "code" : "oral"
    }]
  },
  "use" : "claim",
  "patient" : {
    "reference" : "Patient/1"
  },
  "created" : "2014-08-16",
  "insurer" : {
    "identifier" : {
      "system" : "http://www.jurisdiction.org/insurers",
      "value" : "555123"
    }
  },
  "requestor" : {
    "reference" : "Organization/1"
  },
  "request" : {
    "identifier" : {
      "system" : "http://happyvalley.com/claim",
      "value" : "12346"
    }
  },
  "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" : 0.00,
        "currency" : "USD"
      }
    },
    {
      "category" : {
        "coding" : [{
          "code" : "benefit"
        }]
      },
      "amount" : {
        "value" : 0.00,
        "currency" : "USD"
      }
    }]
  },
  {
    "itemSequence" : 2,
    "adjudication" : [{
      "category" : {
        "coding" : [{
          "code" : "eligible"
        }]
      },
      "amount" : {
        "value" : 105.00,
        "currency" : "USD"
      }
    },
    {
      "category" : {
        "coding" : [{
          "code" : "eligpercent"
        }]
      },
      "value" : 80.00
    },
    {
      "category" : {
        "coding" : [{
          "code" : "benefit"
        }]
      },
      "amount" : {
        "value" : 84.00,
        "currency" : "USD"
      }
    }]
  },
  {
    "itemSequence" : 3,
    "adjudication" : [{
      "category" : {
        "coding" : [{
          "code" : "eligible"
        }]
      },
      "amount" : {
        "value" : 750.00,
        "currency" : "USD"
      }
    },
    {
      "category" : {
        "coding" : [{
          "code" : "eligpercent"
        }]
      },
      "value" : 80.00
    },
    {
      "category" : {
        "coding" : [{
          "code" : "benefit"
        }]
      },
      "amount" : {
        "value" : 600.00,
        "currency" : "USD"
      }
    }],
    "detail" : [{
      "detailSequence" : 1,
      "adjudication" : [{
        "category" : {
          "coding" : [{
            "code" : "eligible"
          }]
        },
        "amount" : {
          "value" : 750.00,
          "currency" : "USD"
        }
      },
      {
        "category" : {
          "coding" : [{
            "code" : "eligpercent"
          }]
        },
        "value" : 80.00
      },
      {
        "category" : {
          "coding" : [{
            "code" : "benefit"
          }]
        },
        "amount" : {
          "value" : 600.00,
          "currency" : "USD"
        }
      }]
    },
    {
      "detailSequence" : 2,
      "adjudication" : [{
        "category" : {
          "coding" : [{
            "code" : "eligible"
          }]
        },
        "amount" : {
          "value" : 0.00,
          "currency" : "USD"
        }
      },
      {
        "category" : {
          "coding" : [{
            "code" : "benefit"
          }]
        },
        "amount" : {
          "value" : 0.00,
          "currency" : "USD"
        }
      }]
    }]
  }],
  "addItem" : [{
    "itemSequence" : [1],
    "productOrService" : {
      "coding" : [{
        "system" : "http://example.org/fhir/oralservicecodes",
        "code" : "1101"
      }]
    },
    "modifier" : [{
      "coding" : [{
        "system" : "http://example.org/fhir/modifiers",
        "code" : "x",
        "display" : "None"
      }]
    }],
    "net" : {
      "value" : 135.57,
      "currency" : "USD"
    },
    "noteNumber" : [101],
    "adjudication" : [{
      "category" : {
        "coding" : [{
          "code" : "eligible"
        }]
      },
      "amount" : {
        "value" : 100.00,
        "currency" : "USD"
      }
    },
    {
      "category" : {
        "coding" : [{
          "code" : "copay"
        }]
      },
      "amount" : {
        "value" : 10.00,
        "currency" : "USD"
      }
    },
    {
      "category" : {
        "coding" : [{
          "code" : "eligpercent"
        }]
      },
      "value" : 80.00
    },
    {
      "category" : {
        "coding" : [{
          "code" : "benefit"
        }]
      },
      "reason" : {
        "coding" : [{
          "system" : "http://terminology.hl7.org/CodeSystem/adjudication-reason",
          "code" : "ar002",
          "display" : "Plan Limit Reached"
        }]
      },
      "amount" : {
        "value" : 72.00,
        "currency" : "USD"
      }
    }]
  },
  {
    "itemSequence" : [1],
    "productOrService" : {
      "coding" : [{
        "system" : "http://example.org/fhir/oralservicecodes",
        "code" : "2141",
        "display" : "Radiograph, bytewing"
      }]
    },
    "net" : {
      "value" : 35.57,
      "currency" : "USD"
    },
    "adjudication" : [{
      "category" : {
        "coding" : [{
          "code" : "eligible"
        }]
      },
      "amount" : {
        "value" : 35.57,
        "currency" : "USD"
      }
    },
    {
      "category" : {
        "coding" : [{
          "code" : "eligpercent"
        }]
      },
      "value" : 80.00
    },
    {
      "category" : {
        "coding" : [{
          "code" : "benefit"
        }]
      },
      "amount" : {
        "value" : 28.47,
        "currency" : "USD"
      }
    }]
  },
  {
    "itemSequence" : [3],
    "detailSequence" : [2],
    "productOrService" : {
      "coding" : [{
        "system" : "http://example.org/fhir/oralservicecodes",
        "code" : "expense"
      }]
    },
    "modifier" : [{
      "coding" : [{
        "system" : "http://example.org/fhir/modifiers",
        "code" : "x",
        "display" : "None"
      }]
    }],
    "net" : {
      "value" : 350.00,
      "currency" : "USD"
    },
    "noteNumber" : [101],
    "adjudication" : [{
      "category" : {
        "coding" : [{
          "code" : "eligible"
        }]
      },
      "amount" : {
        "value" : 350.00,
        "currency" : "USD"
      }
    },
    {
      "category" : {
        "coding" : [{
          "code" : "eligpercent"
        }]
      },
      "value" : 80.00
    },
    {
      "category" : {
        "coding" : [{
          "code" : "benefit"
        }]
      },
      "amount" : {
        "value" : 270.00,
        "currency" : "USD"
      }
    }]
  }],
  "total" : [{
    "category" : {
      "coding" : [{
        "code" : "submitted"
      }]
    },
    "amount" : {
      "value" : 1340.57,
      "currency" : "USD"
    }
  },
  {
    "category" : {
      "coding" : [{
        "code" : "benefit"
      }]
    },
    "amount" : {
      "value" : 1054.47,
      "currency" : "USD"
    }
  }],
  "payment" : {
    "type" : {
      "coding" : [{
        "system" : "http://terminology.hl7.org/CodeSystem/ex-paymenttype",
        "code" : "complete"
      }]
    },
    "date" : "2014-08-31",
    "amount" : {
      "value" : 100.47,
      "currency" : "USD"
    },
    "identifier" : {
      "system" : "http://www.BenefitsInc.com/fhir/paymentidentifier",
      "value" : "201408-2-15507"
    }
  },
  "processNote" : [{
    "number" : 101,
    "type" : "print",
    "text" : "Package codes are not permitted. Codes replaced by Insurer.",
    "language" : {
      "coding" : [{
        "system" : "urn:ietf:bcp:47",
        "code" : "en-CA"
      }]
    }
  }]
}