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7.2.5 Resource ClaimResponse - Examples

Example Index:

General Person Primary Coverage ExampleXMLJSON

7.2.5.1 General-Primary

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>

JSON

General Person Primary Coverage Example

Raw JSON (Canonical)

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

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.