General Person Primary Coverage Example (id = "R3500")

<?xml version="1.0" encoding="UTF-8"?>

<ClaimResponse xmlns="http://hl7.org/fhir">

  <id value="R3500"/> 

  <text> 
    <status value="generated"/> 
    <div xmlns="http://www.w3.org/1999/xhtml">A human-readable rendering of the ClaimResponse</div> 
  </text> 

  <identifier> 
    <system value="http://www.BenefitsInc.com/fhir/remittance"/> 
    <value value="R3500"/> 
  </identifier> 

  <status value="active"/> 

  <type> 
    <coding> 
      <system value="http://terminology.hl7.org/CodeSystem/claim-type"/> 
      <code value="oral"/> 
    </coding> 
  </type> 

  <subType> 
    <coding> 
      <system value="http://terminology.hl7.org/CodeSystem/ex-claimsubtype"/> 
      <code value="emergency"/> 
    </coding> 
  </subType> 

  <use value="claim"/> 
  
  <patient> 
    <reference value="Patient/1"/> 
  </patient> 

  <created value="2014-08-16"/> 

  <insurer> 
    <identifier> 
      <system value="http://www.jurisdiction.org/insurers"/> 
      <value value="555123"/> 
    </identifier> 
  </insurer> 

  <requestor> 
    <reference value="Organization/1"/> 
  </requestor> 

  <request> 
    <reference value="http://www.BenefitsInc.com/fhir/oralhealthclaim/15476332402"/> 
  </request> 

  <outcome value="complete"/> 
  
  <disposition value="Claim settled as per contract."/> 

  <payeeType> 
    <coding> 
      <system value="http://terminology.hl7.org/CodeSystem/payeetype"/> 
      <code value="provider"/> 
    </coding> 
  </payeeType> 

    <!--   Adjudication details   -->

  <item> 

    <itemSequence value="1"/>  

    <adjudication> 
      <category> 
        <coding> 
          <code value="eligible"/> 
        </coding> 
      </category> 
      <amount> 
        <value value="135.57"/> 
        <currency value="USD"/> 
      </amount> 
    </adjudication> 

    <adjudication> 
      <category> 
        <coding> 
          <code value="copay"/> 
        </coding> 
      </category> 
      <amount> 
        <value value="10.00"/> 
        <currency value="USD"/> 
      </amount>   
    </adjudication> 

    <adjudication> 
      <category> 
        <coding> 
          <code value="eligpercent"/> 
        </coding> 
      </category> 
      <value value="80.00"/> 
    </adjudication> 
    <adjudication> 
      <category> 
        <coding> 
          <code value="benefit"/> 
        </coding> 
      </category> 
      <reason> 
        <coding> 
          <system value="http://terminology.hl7.org/CodeSystem/adjudication-reason"/> 
          <code value="ar002"/> 
          <display value="Plan Limit Reached"/> 
            <!--   should have paid 100.47   -->
        </coding> 
      </reason> 
      <amount> 
        <value value="90.47"/> 
        <currency value="USD"/> 
      </amount>   
    </adjudication> 

  </item> 

  <total> 
    <category> 
      <coding> 
        <code value="submitted"/> 
      </coding> 
    </category> 
    <amount> 
      <value value="135.57"/> 
      <currency value="USD"/>  
    </amount>  
  </total> 
  
  <total> 
    <category> 
      <coding> 
        <code value="benefit"/> 
      </coding> 
    </category> 
    <amount> 
      <value value="90.47"/> 
      <currency value="USD"/>  
    </amount>  
  </total> 

    <!--   Payment details   -->
  <payment> 
    <type> 
      <coding> 
        <system value="http://terminology.hl7.org/CodeSystem/ex-paymenttype"/> 
        <code value="complete"/> 
      </coding> 
    </type>   

    <date value="2014-08-31"/> 

    <amount> 
      <value value="100.47"/> 
      <currency value="USD"/> 
    </amount>   

    <identifier> 
      <system value="http://www.BenefitsInc.com/fhir/paymentidentifier"/> 
      <value value="201408-2-1569478"/> 
    </identifier>   
  </payment> 
</ClaimResponse>