Claimresponse-example.xml

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

<ClaimResponse xmlns="http://hl7.org/fhir">

  <id value="R3500"/> 

  <text> 
    <status value="generated"/> 
    <div xmlns="http://www.w3.org/1999/xhtml">A human-readable rendering of the ClaimResponse</div> 
  </text> 

  <identifier> 
    <system value="http://www.BenefitsInc.com/fhir/remittance"/> 
    <value value="R3500"/> 
  </identifier> 

  <status value="active"/> 

  <patient> 
    <reference value="Patient/1"/> 
  </patient> 

  <created value="2014-08-16"/> 

  <insurer> 
    <identifier> 
      <system value="http://www.jurisdiction.org/insurers"/> 
      <value value="555123"/> 
    </identifier> 
  </insurer> 

  <requestProvider> 
    <reference value="Practitioner/1"/> 
  </requestProvider> 

  <requestOrganization> 
    <reference value="Organization/1"/> 
  </requestOrganization> 

  <request> 
    <reference value="http://www.BenefitsInc.com/fhir/oralhealthclaim/15476332402"/> 
  </request> 

  <outcome> 
    <coding> 
      <system value="http://hl7.org/fhir/remittance-outcome"/> 
      <code value="complete"/> 
    </coding> 
  </outcome> 

  <disposition value="Claim settled as per contract."/> 

  <payeeType> 
    <coding> 
      <system value="http://hl7.org/fhir/payeetype"/> 
      <code value="provider"/> 
    </coding> 
  </payeeType> 

  <!--   Adjudication details   -->

  <item> 

    <sequenceLinkId value="1"/>  

    <adjudication> 
      <category> 
        <coding> 
          <code value="eligible"/> 
        </coding> 
      </category> 
      <amount> 
        <value value="135.57"/> 
        <system value="urn:iso:std:iso:4217"/> 
        <code value="USD"/> 
      </amount> 
    </adjudication> 

    <adjudication> 
      <category> 
        <coding> 
          <code value="copay"/> 
        </coding> 
      </category> 
      <amount> 
        <value value="10.00"/> 
        <system value="urn:iso:std:iso:4217"/> 
        <code value="USD"/> 
      </amount>   
    </adjudication> 

    <adjudication> 
      <category> 
        <coding> 
          <code value="eligpercent"/> 
        </coding> 
      </category> 
      <value value="80.00"/> 
    </adjudication> 

    <adjudication> 
      <category> 
        <coding> 
          <code value="benefit"/> 
        </coding> 
      </category> 
      <amount> 
        <value value="100.47"/> 
        <system value="urn:iso:std:iso:4217"/> 
        <code value="USD"/> 
      </amount>   
    </adjudication> 

  </item> 

  <totalCost> 
    <value value="135.57"/> 
    <system value="urn:iso:std:iso:4217"/> 
    <code value="USD"/> 
  </totalCost>   

  <totalBenefit> 
    <value value="100.47"/> 
    <system value="urn:iso:std:iso:4217"/> 
    <code value="USD"/> 
  </totalBenefit> 

  <!--   Payment details   -->
  <payment> 
    <type> 
      <coding> 
        <system value="http://hl7.org/fhir/ex-paymenttype"/> 
        <code value="complete"/> 
      </coding> 
    </type>   

    <date value="2014-08-31"/> 

    <amount> 
      <value value="100.47"/> 
      <system value="urn:iso:std:iso:4217"/> 
      <code value="USD"/> 
    </amount>   

    <identifier> 
      <system value="http://www.BenefitsInc.com/fhir/paymentidentifier"/> 
      <value value="201408-2-1569478"/> 
    </identifier>   
  </payment> 
</ClaimResponse>