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"
}]
}
}]
}
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.
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