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"
        }]
      },
      "quantity" : {
        "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"
          }]
        },
        "quantity" : {
          "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"
          }]
        },
        "quantity" : {
          "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"
            }]
          },
          "quantity" : {
            "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"
            }]
          },
          "quantity" : {
            "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"
            }]
          },
          "quantity" : {
            "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"
          }]
        },
        "quantity" : {
          "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" : {
      "coding" : [{
        "system" : "http://hl7.org/fhir/note-type",
        "code" : "display"
      }]
    },
    "text" : "After hours surcharge declined",
    "language" : {
      "coding" : [{
        "system" : "urn:ietf:bcp:47",
        "code" : "en-CA"
      }]
    }
  }]
}