Publish-box (todo)
Financial Management Work Group | Maturity Level: N/A | Standards Status: Informative | Compartments: Patient, Practitioner |
Raw JSON (canonical form + also see JSON Format Specification)
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" }] }, "quantity" : { "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" }] }, "quantity" : { "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" }] }, "quantity" : { "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" }] }, "quantity" : { "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" }] }, "quantity" : { "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" }] }, "quantity" : { "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" : { "coding" : [{ "system" : "http://hl7.org/fhir/note-type", "code" : "print" }] }, "text" : "Package codes are not permitted. Codes replaced by Insurer.", "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.
FHIR ®© HL7.org 2011+. FHIR R6 hl7.fhir.core#6.0.0-ballot2 generated on Mon, Aug 12, 2024 16:58+0800.
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