QI-Core Implementation Guide
5.0.0 - STU5 United States of America flag

This page is part of the Quality Improvement Core Framework (v5.0.0: STU5 (v5.0.0)) based on FHIR R4. The current version which supercedes this version is 4.1.1. For a full list of available versions, see the Directory of published versions

: ClaimResponse example - JSON Representation

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{
  "resourceType" : "ClaimResponse",
  "id" : "example",
  "meta" : {
    "profile" : [
      "http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-claimresponse"
    ]
  },
  "text" : {
    "status" : "generated",
    "div" : "<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/3.1.0/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/3.1.0/CodeSystem-adjudication.html\">Adjudication Value Codes</a>#submitted)</span></p><h3>Amounts</h3><table class=\"grid\"><tr><td>-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td>*</td><td>235.40</td><td>USD</td></tr></table></blockquote></blockquote></div>"
  },
  "status" : "active",
  "type" : {
    "coding" : [
      {
        "system" : "http://terminology.hl7.org/CodeSystem/claim-type",
        "code" : "vision"
      }
    ]
  },
  "use" : "preauthorization",
  "patient" : {
    "reference" : "Patient/example"
  },
  "created" : "2018-02-24",
  "insurer" : {
    "reference" : "Organization/example"
  },
  "requestor" : {
    "reference" : "Practitioner/example"
  },
  "request" : {
    "reference" : "Claim/example"
  },
  "outcome" : "queued",
  "item" : [
    {
      "itemSequence" : 1,
      "adjudication" : [
        {
          "category" : {
            "coding" : [
              {
                "system" : "http://terminology.hl7.org/CodeSystem/adjudication",
                "code" : "submitted"
              }
            ]
          },
          "amount" : {
            "value" : 235.40,
            "currency" : "USD"
          }
        }
      ]
    }
  ]
}