Claimresponse-example.xml

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

Raw XML

<ClaimResponse xmlns="http://hl7.org/fhir">
  <id value="R3500"/>
  <text>
    <status value="generated"/>
    <div xmlns="http://www.w3.org/1999/xhtml"><!-- Snipped for brevity --></div>
  </text>
  <identifier>
    <system value="http://www.BenefitsInc.com/fhir/remittance"/>
    <value value="R3500"/>
  </identifier>
  <request>
    <reference value="http://www.BenefitsInc.com/fhir/oralhealthclaim/15476332402"/>
  </request>
  <created value="2014-08-16"/>
  <organization>
    <reference value="Organization/2"/>
  </organization>
  <requestOrganization>
    <reference value="Organization/1"/>
  </requestOrganization>
  <outcome value="complete"/>
  <disposition value="Claim settled as per contract."/>
  <payeeType>
    <system value="http://hl7.org/fhir/payeetype"/>
    <code value="provider"/>
  </payeeType><!--    Adjudication details    -->
  <item>
    <sequenceLinkId value="1"/>
    <adjudication>
      <code>
        <code value="eligible"/>
      </code>
      <amount>
        <value value="135.57"/>
        <system value="urn:std:iso:4217"/>
        <code value="USD"/>
      </amount>
    </adjudication>
    <adjudication>
      <code>
        <code value="copay"/>
      </code>
      <amount>
        <value value="10.00"/>
        <system value="urn:std:iso:4217"/>
        <code value="USD"/>
      </amount>
    </adjudication>
    <adjudication>
      <code>
        <code value="eligpercent"/>
      </code>
      <value value="80.00"/>
    </adjudication>
    <adjudication>
      <code>
        <code value="benefit"/>
      </code>
      <amount>
        <value value="100.47"/>
        <system value="urn:std:iso:4217"/>
        <code value="USD"/>
      </amount>
    </adjudication>
  </item>
  <totalCost>
    <value value="135.57"/>
    <system value="urn:std:iso:4217"/>
    <code value="USD"/>
  </totalCost>
  <totalBenefit>
    <value value="100.47"/>
    <system value="urn:std:iso:4217"/>
    <code value="USD"/>
  </totalBenefit><!--    Payment details    -->
  <paymentDate value="2014-08-31"/>
  <paymentAmount>
    <value value="100.47"/>
    <system value="urn:std:iso:4217"/>
    <code value="USD"/>
  </paymentAmount>
  <paymentRef>
    <system value="http://www.BenefitsInc.com/fhir/paymentRef"/>
    <value value="201408-2-1569478"/>
  </paymentRef>
</ClaimResponse>