Claimresponse-example-2.json

A ClaimResponse for a Claim that contains processing errors

{
  "resourceType": "ClaimResponse",
  "id": "R3501",
  "text": {
    "status": "generated",
    "div": "<div xmlns=\"http://www.w3.org/1999/xhtml\">A human-readable rendering of the ClaimResponse that demonstrates returning errors</div>"
  },
  "identifier": [
    {
      "system": "http://www.BenefitsInc.com/fhir/remittance",
      "value": "R3501"
    }
  ],
  "status": "active",
  "patient": {
    "reference": "Patient/1"
  },
  "created": "2014-08-16",
  "insurer": {
    "identifier": {
      "system": "http://www.jurisdiction.org/insurers",
      "value": "555123"
    }
  },
  "requestProvider": {
    "reference": "Practitioner/1"
  },
  "requestOrganization": {
    "reference": "Organization/1"
  },
  "request": {
    "reference": "Claim/100156"
  },
  "outcome": "error",
  "disposition": "Claim could not be processed",
  "item": [
    {
      "itemSequence": 1,
      "noteNumber": [
        1
      ]
    },
    {
      "itemSequence": 2,
      "noteNumber": [
        1
      ]
    },
    {
      "itemSequence": 3,
      "noteNumber": [
        1
      ],
      "detail": [
        {
          "detailSequence": 1,
          "noteNumber": [
            1
          ]
        },
        {
          "detailSequence": 2,
          "noteNumber": [
            1
          ]
        }
      ]
    }
  ],
  "error": [
    {
      "itemSequence": 3,
      "detailSequence": 2,
      "code": {
        "coding": [
          {
            "system": "http://hl7.org/fhir/adjudication-error",
            "code": "a002"
          }
        ]
      }
    }
  ],
  "form": {
    "coding": [
      {
        "system": "http://hl7.org/fhir/forms-codes",
        "code": "2"
      }
    ]
  },
  "processNote": [
    {
      "number": 1,
      "type": "display",
      "text": "Invalid claim",
      "language": {
        "coding": [
          {
            "system": "urn:ietf:bcp:47",
            "code": "en-CA"
          }
        ]
      }
    }
  ],
  "communicationRequest": [
    {
      "reference": "CommunicationRequest/fm-solicit"
    }
  ]
}