Release 5

This page is part of the FHIR Specification (v5.0.0: R5 - STU). This is the current published version in it's permanent home (it will always be available at this URL). For a full list of available versions, see the Directory of published versions . Page versions: R5 R4B R4 R3

Example ClaimResponse/R3500 (Turtle)

Financial Management Work GroupMaturity Level: N/AStandards Status: InformativeCompartments: Patient, Practitioner

Raw Turtle (+ also see Turtle/RDF Format Specification)

General Person Primary Coverage Example

@prefix fhir: <http://hl7.org/fhir/> .
@prefix owl: <http://www.w3.org/2002/07/owl#> .
@prefix rdfs: <http://www.w3.org/2000/01/rdf-schema#> .
@prefix xsd: <http://www.w3.org/2001/XMLSchema#> .

# - resource -------------------------------------------------------------------

[a fhir:ClaimResponse ;
  fhir:nodeRole fhir:treeRoot ;
  fhir:id [ fhir:v "R3500"] ; # 
  fhir:text [
     fhir:status [ fhir:v "generated" ] ;
     fhir:div "<div xmlns=\"http://www.w3.org/1999/xhtml\">A human-readable rendering of the ClaimResponse</div>"
  ] ; # 
  fhir:identifier ( [
     fhir:system [ fhir:v "http://www.BenefitsInc.com/fhir/remittance"^^xsd:anyURI ] ;
     fhir:value [ fhir:v "R3500" ]
  ] ) ; # 
  fhir:status [ fhir:v "active"] ; # 
  fhir:type [
     fhir:coding ( [
       fhir:system [ fhir:v "http://terminology.hl7.org/CodeSystem/claim-type"^^xsd:anyURI ] ;
       fhir:code [ fhir:v "oral" ]
     ] )
  ] ; # 
  fhir:subType [
     fhir:coding ( [
       fhir:system [ fhir:v "http://terminology.hl7.org/CodeSystem/ex-claimsubtype"^^xsd:anyURI ] ;
       fhir:code [ fhir:v "emergency" ]
     ] )
  ] ; # 
  fhir:use [ fhir:v "claim"] ; # 
  fhir:patient [
     fhir:reference [ fhir:v "Patient/1" ]
  ] ; # 
  fhir:created [ fhir:v "2014-08-16"^^xsd:date] ; # 
  fhir:insurer [
     fhir:identifier [
       fhir:system [ fhir:v "http://www.jurisdiction.org/insurers"^^xsd:anyURI ] ;
       fhir:value [ fhir:v "555123" ]
     ]
  ] ; # 
  fhir:requestor [
     fhir:reference [ fhir:v "Organization/1" ]
  ] ; # 
  fhir:request [
     fhir:link <http://www.BenefitsInc.com/fhir/oralhealthclaim/15476332402> ;
     fhir:reference [ fhir:v "http://www.BenefitsInc.com/fhir/oralhealthclaim/15476332402" ]
  ] ; # 
  fhir:outcome [ fhir:v "complete"] ; # 
  fhir:disposition [ fhir:v "Claim settled as per contract."] ; # 
  fhir:payeeType [
     fhir:coding ( [
       fhir:system [ fhir:v "http://terminology.hl7.org/CodeSystem/payeetype"^^xsd:anyURI ] ;
       fhir:code [ fhir:v "provider" ]
     ] )
  ] ; # 
  fhir:item ( [
     fhir:itemSequence [ fhir:v "1"^^xsd:positiveInteger ] ;
     fhir:adjudication ( [
       fhir:category [
         fhir:coding ( [
           fhir:code [ fhir:v "eligible" ]
         ] )
       ] ;
       fhir:amount [
         fhir:value [ fhir:v "135.57"^^xsd:decimal ] ;
         fhir:currency [ fhir:v "USD" ]
       ]
     ] [
       fhir:category [
         fhir:coding ( [
           fhir:code [ fhir:v "copay" ]
         ] )
       ] ;
       fhir:amount [
         fhir:value [ fhir:v "10.00"^^xsd:decimal ] ;
         fhir:currency [ fhir:v "USD" ]
       ]
     ] [
       fhir:category [
         fhir:coding ( [
           fhir:code [ fhir:v "eligpercent" ]
         ] )
       ] ;
       fhir:quantity [
         fhir:value [ fhir:v "80.00"^^xsd:decimal ]
       ]
     ] [
       fhir:category [
         fhir:coding ( [
           fhir:code [ fhir:v "benefit" ]
         ] )
       ] ;
       fhir:reason [
         fhir:coding ( [
           fhir:system [ fhir:v "http://terminology.hl7.org/CodeSystem/adjudication-reason"^^xsd:anyURI ] ;
           fhir:code [ fhir:v "ar002" ] ;
           fhir:display [ fhir:v "Plan Limit Reached" ]
         ] ) #   should have paid 100.47  
       ] ;
       fhir:amount [
         fhir:value [ fhir:v "90.47"^^xsd:decimal ] ;
         fhir:currency [ fhir:v "USD" ]
       ]
     ] )
  ] ) ; #   Adjudication details  
  fhir:total ( [
     fhir:category [
       fhir:coding ( [
         fhir:code [ fhir:v "submitted" ]
       ] )
     ] ;
     fhir:amount [
       fhir:value [ fhir:v "135.57"^^xsd:decimal ] ;
       fhir:currency [ fhir:v "USD" ]
     ]
  ] [
     fhir:category [
       fhir:coding ( [
         fhir:code [ fhir:v "benefit" ]
       ] )
     ] ;
     fhir:amount [
       fhir:value [ fhir:v "90.47"^^xsd:decimal ] ;
       fhir:currency [ fhir:v "USD" ]
     ]
  ] ) ; # 
  fhir:payment [
     fhir:type [
       fhir:coding ( [
         fhir:system [ fhir:v "http://terminology.hl7.org/CodeSystem/ex-paymenttype"^^xsd:anyURI ] ;
         fhir:code [ fhir:v "complete" ]
       ] )
     ] ;
     fhir:date [ fhir:v "2014-08-31"^^xsd:date ] ;
     fhir:amount [
       fhir:value [ fhir:v "100.47"^^xsd:decimal ] ;
       fhir:currency [ fhir:v "USD" ]
     ] ;
     fhir:identifier [
       fhir:system [ fhir:v "http://www.BenefitsInc.com/fhir/paymentidentifier"^^xsd:anyURI ] ;
       fhir:value [ fhir:v "201408-2-1569478" ]
     ]
  ]] . #   Payment details  

# -------------------------------------------------------------------------------------

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.