QI-Core Implementation Guide
7.0.2 - STU 7

QI-Core Implementation Guide - Downloaded Version 7.0.2 See the Directory of published versions

## : ClaimResponse example - XML Representation

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    <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 class="res-header-id"><b>Generated Narrative: ClaimResponse example</b></p><a name="example"> </a><a name="hcexample"> </a><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"/><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>: <span title="Codes:{http://terminology.hl7.org/CodeSystem/claim-type vision}">Vision</span></p><p><b>use</b>: Preauthorization</p><p><b>patient</b>: <a href="Patient-example.html">Jim Chalmers  Male, DoB: 1974-12-25 ( Medical record number (use: usual, period: 2001-05-06 --&gt; (ongoing)))</a></p><p><b>created</b>: 2018-02-24</p><p><b>insurer</b>: <a href="Organization-example.html">Organization Health Level Seven International</a></p><p><b>requestor</b>: <a href="Practitioner-example.html">Practitioner Adam Careful </a></p><p><b>request</b>: <a href="Claim-example.html">Claim: identifier = http://example.org/claim#6612346; status = active; type = Vision; use = claim; created = 2014-08-16; priority = Normal</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>: <span title="Codes:{http://terminology.hl7.org/CodeSystem/adjudication submitted}">Submitted Amount</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>United States dollar</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>