QI-Core Implementation Guide
6.0.0-ballot - ballot United States of America flag

This page is part of the Quality Improvement Core Framework (v6.0.0-ballot: STU6 (v6.0.0) Ballot 1) based on FHIR R4. The current version which supercedes this version is 5.0.0. For a full list of available versions, see the Directory of published versions

: ClaimResponse example - XML Representation

Raw xml | Download



<ClaimResponse xmlns="http://hl7.org/fhir">
  <id value="example"/>
  <meta>
    <profile
             value="http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-claimresponse"/>
  </meta>
  <text>
    <status value="generated"/>
    <div xmlns="http://www.w3.org/1999/xhtml"><p><b>Generated Narrative: ClaimResponse</b><a name="example"> </a></p><div style="display: inline-block; background-color: #d9e0e7; padding: 6px; margin: 4px; border: 1px solid #8da1b4; border-radius: 5px; line-height: 60%"><p style="margin-bottom: 0px">Resource ClaimResponse &quot;example&quot; </p><p style="margin-bottom: 0px">Profile: <a href="StructureDefinition-qicore-claimresponse.html">QICore ClaimResponse</a></p></div><p><b>status</b>: active</p><p><b>type</b>: Vision <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="http://terminology.hl7.org/5.0.0/CodeSystem-claim-type.html">Claim Type Codes</a>#vision)</span></p><p><b>use</b>: preauthorization</p><p><b>patient</b>: <a href="Patient-example.html">Patient/example</a> &quot; CHALMERS&quot;</p><p><b>created</b>: 2018-02-24</p><p><b>insurer</b>: <a href="Organization-example.html">Organization/example</a> &quot;Health Level Seven International&quot;</p><p><b>requestor</b>: <a href="Practitioner-example.html">Practitioner/example</a> &quot; CAREFUL&quot;</p><p><b>request</b>: <a href="Claim-example.html">Claim/example</a></p><p><b>outcome</b>: queued</p><blockquote><p><b>item</b></p><p><b>itemSequence</b>: 1</p><blockquote><p><b>adjudication</b></p><p><b>category</b>: Submitted Amount <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="http://terminology.hl7.org/5.0.0/CodeSystem-adjudication.html">Adjudication Value Codes</a>#submitted)</span></p><h3>Amounts</h3><table class="grid"><tr><td style="display: none">-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td style="display: none">*</td><td>235.40</td><td>USD</td></tr></table></blockquote></blockquote></div>
  </text>
  <status value="active"/>
  <type>
    <coding>
      <system value="http://terminology.hl7.org/CodeSystem/claim-type"/>
      <code value="vision"/>
    </coding>
  </type>
  <use value="preauthorization"/>
  <patient>
    <reference value="Patient/example"/>
  </patient>
  <created value="2018-02-24"/>
  <insurer>
    <reference value="Organization/example"/>
  </insurer>
  <requestor>
    <reference value="Practitioner/example"/>
  </requestor>
  <request>
    <reference value="Claim/example"/>
  </request>
  <outcome value="queued"/>
  <item>
    <itemSequence value="1"/>
    <adjudication>
      <category>
        <coding>
          <system value="http://terminology.hl7.org/CodeSystem/adjudication"/>
          <code value="submitted"/>
        </coding>
      </category>
      <amount>
        <value value="235.40"/>
        <currency value="USD"/>
      </amount>
    </adjudication>
  </item>
</ClaimResponse>