Release 4
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. Page versions: R5 R4B R4
| Financial Management Work Group | Maturity Level: N/A | Standards Status: Informative | Compartments: Patient, Practitioner |
Raw JSON (canonical form + also see JSON Format Specification)
Primary insurance response to a 3Tier Vision Claim
{
"resourceType": "ClaimResponse",
"id": "R3502",
"text": {
"status": "generated",
"div": "<div xmlns=\"http://www.w3.org/1999/xhtml\">A human-readable rendering of the ClaimResponse</div>"
},
"identifier": [
{
"system": "http://thebenefitcompany.com/claimresponse",
"value": "CR6532875367"
}
],
"status": "active",
"type": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/claim-type",
"code": "vision"
}
]
},
"use": "claim",
"patient": {
"reference": "Patient/1"
},
"created": "2014-08-16",
"insurer": {
"reference": "Organization/2"
},
"requestor": {
"reference": "Organization/1"
},
"request": {
"identifier": {
"system": "http://happysight.com/claim",
"value": "6612346"
}
},
"outcome": "complete",
"disposition": "Claim settled as per contract.",
"payeeType": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/payeetype",
"code": "provider"
}
]
},
"item": [
{
"itemSequence": 1,
"adjudication": [
{
"category": {
"coding": [
{
"code": "eligible"
}
]
},
"amount": {
"value": 235.40,
"currency": "USD"
}
},
{
"category": {
"coding": [
{
"code": "copay"
}
]
},
"amount": {
"value": 20.00,
"currency": "USD"
}
},
{
"category": {
"coding": [
{
"code": "eligpercent"
}
]
},
"value": 80.00
},
{
"category": {
"coding": [
{
"code": "benefit"
}
]
},
"amount": {
"value": 172.32,
"currency": "USD"
}
}
],
"detail": [
{
"detailSequence": 1,
"noteNumber": [
1
],
"adjudication": [
{
"category": {
"coding": [
{
"code": "eligible"
}
]
},
"amount": {
"value": 100.00,
"currency": "USD"
}
},
{
"category": {
"coding": [
{
"code": "copay"
}
]
},
"amount": {
"value": 20.00,
"currency": "USD"
}
},
{
"category": {
"coding": [
{
"code": "eligpercent"
}
]
},
"value": 80.00
},
{
"category": {
"coding": [
{
"code": "benefit"
}
]
},
"amount": {
"value": 80.00,
"currency": "USD"
}
}
]
},
{
"detailSequence": 2,
"noteNumber": [
1
],
"adjudication": [
{
"category": {
"coding": [
{
"code": "eligible"
}
]
},
"amount": {
"value": 110.00,
"currency": "USD"
}
},
{
"category": {
"coding": [
{
"code": "eligpercent"
}
]
},
"value": 80.00
},
{
"category": {
"coding": [
{
"code": "benefit"
}
]
},
"amount": {
"value": 88.00,
"currency": "USD"
}
}
],
"subDetail": [
{
"subDetailSequence": 1,
"noteNumber": [
1
],
"adjudication": [
{
"category": {
"coding": [
{
"code": "eligible"
}
]
},
"amount": {
"value": 60.00,
"currency": "USD"
}
},
{
"category": {
"coding": [
{
"code": "eligpercent"
}
]
},
"value": 80.00
},
{
"category": {
"coding": [
{
"code": "benefit"
}
]
},
"amount": {
"value": 48.00,
"currency": "USD"
}
}
]
},
{
"subDetailSequence": 2,
"adjudication": [
{
"category": {
"coding": [
{
"code": "eligible"
}
]
},
"amount": {
"value": 30.00,
"currency": "USD"
}
},
{
"category": {
"coding": [
{
"code": "eligpercent"
}
]
},
"value": 80.00
},
{
"category": {
"coding": [
{
"code": "benefit"
}
]
},
"amount": {
"value": 24.00,
"currency": "USD"
}
}
]
},
{
"subDetailSequence": 3,
"noteNumber": [
1
],
"adjudication": [
{
"category": {
"coding": [
{
"code": "eligible"
}
]
},
"amount": {
"value": 10.00,
"currency": "USD"
}
},
{
"category": {
"coding": [
{
"code": "eligpercent"
}
]
},
"value": 80.00
},
{
"category": {
"coding": [
{
"code": "benefit"
}
]
},
"amount": {
"value": 8.00,
"currency": "USD"
}
}
]
}
]
},
{
"detailSequence": 3,
"noteNumber": [
1
],
"adjudication": [
{
"category": {
"coding": [
{
"code": "eligible"
}
]
},
"amount": {
"value": 200.00,
"currency": "USD"
}
},
{
"category": {
"coding": [
{
"code": "eligpercent"
}
]
},
"value": 80.00
},
{
"category": {
"coding": [
{
"code": "benefit"
}
]
},
"amount": {
"value": 14.00,
"currency": "USD"
}
}
]
}
]
}
],
"total": [
{
"category": {
"coding": [
{
"code": "submitted"
}
]
},
"amount": {
"value": 235.40,
"currency": "USD"
}
},
{
"category": {
"coding": [
{
"code": "benefit"
}
]
},
"amount": {
"value": 182.00,
"currency": "USD"
}
}
],
"payment": {
"type": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/ex-paymenttype",
"code": "complete"
}
]
},
"adjustment": {
"value": 75.00,
"currency": "USD"
},
"adjustmentReason": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/payment-adjustment-reason",
"code": "a002",
"display": "Prior Overpayment"
}
]
},
"date": "2014-08-16",
"amount": {
"value": 107.00,
"currency": "USD"
},
"identifier": {
"system": "http://thebenefitcompany.com/paymentidentifier",
"value": "201416-123456"
}
},
"processNote": [
{
"number": 1,
"type": "display",
"text": "After hours surcharge declined",
"language": {
"coding": [
{
"system": "urn:ietf:bcp:47",
"code": "en-CA"
}
]
}
}
]
}
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.
®© HL7.org 2011+. FHIR Release 4 (Technical Correction #1) (v4.0.1) generated on Fri, Nov 1, 2019 09:34+1100. QA Page
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