Claimresponse-example-2.xml

A ClaimResponse for a Claim that contains processing errors (id = "R3501")

<ClaimResponse xmlns="http://hl7.org/fhir">

  <id value="R3501"/> 

  <text> 
    <status value="generated"/> 
    <div xmlns="http://www.w3.org/1999/xhtml">A human-readable rendering of the ClaimResponse that demonstrates returning errors</div> 
  </text> 

  <identifier> 
    <system value="http://www.BenefitsInc.com/fhir/remittance"/> 
    <value value="R3501"/> 
  </identifier> 

  <status value="active"/> 

  <type> 
    <coding> 
      <system value="http://hl7.org/fhir/claim-type"/> 
      <code value="oral"/> 
    </coding> 
  </type> 

  <use value="complete"/> 
  
  <patient> 
    <reference value="Patient/1"/> 
  </patient> 

  <created value="2014-08-16"/> 

  <insurer> 
    <identifier> 
      <system value="http://www.jurisdiction.org/insurers"/> 
      <value value="555123"/> 
    </identifier> 
  </insurer> 

  <requestProvider> 
    <reference value="Practitioner/1"/> 
  </requestProvider> 

  <request> 
    <reference value="Claim/100156"/> 
  </request> 

  <outcome value="error"/> 
  
  <disposition value="Claim could not be processed"/> 
  
  <item> 
    <itemSequence value="1"/> 
    <noteNumber value="1"/> 
  </item> 

  <item> 
    <itemSequence value="2"/> 
    <noteNumber value="1"/> 
  </item> 
  
  <item> 
    <itemSequence value="3"/> 
    <noteNumber value="1"/> 
    
    <detail> 
      <detailSequence value="1"/> 
      <noteNumber value="1"/> 
    </detail> 
    
    <detail> 
      <detailSequence value="2"/> 
      <noteNumber value="1"/> 
    </detail> 
  </item> 
  
  <!--   Detailed error description   -->
  <error> 
    <itemSequence value="3"/> 
    <detailSequence value="2"/> 
    <code> 
      <coding> 
        <system value="http://hl7.org/fhir/adjudication-error"/> 
        <code value="a002"/> 
      </coding> 
    </code> 
  </error> 

  <form> 
    <coding> 
      <system value="http://hl7.org/fhir/forms-codes"/> 
      <code value="2"/> 
    </coding> 
  </form> 
  
  <processNote> 
    <number value="1"/> 
    <type value="display"/> 
    <text value="Invalid claim"/> 
    <language> 
      <coding> 
        <system value="urn:ietf:bcp:47"/> 
        <code value="en-CA"/> 
      </coding> 
    </language> 
  </processNote> 
  
  <communicationRequest> 
    <reference value="CommunicationRequest/fm-solicit"/> 
  </communicationRequest> 
</ClaimResponse>