R4 Ballot #1 (Mixed Normative/Trial use)
FinancialThis page is part of the FHIR Specification (v3.3.0: R4 Ballot 2). The current version which supercedes this version is 5.0.0. For a full list of available versions, see the Directory of published versions 
. Page versions: R5 R4B R4
| Financial Management Work Group | Maturity Level: N/A | Ballot Status: Informative | Compartments: Patient, Practitioner |
A ClaimResponse demonstrating Payor service code substitutions
{
"resourceType": "ClaimResponse",
"id": "R3503",
"text": {
"status": "generated",
"div": "<div xmlns=\"http://www.w3.org/1999/xhtml\">A human-readable rendering of the ClaimResponse to Claim Oral Average with additional items</div>"
},
"identifier": [
{
"system": "http://www.BenefitsInc.com/fhir/remittance",
"value": "R3503"
}
],
"status": "active",
"type": {
"coding": [
{
"system": "http://hl7.org/fhir/claim-type",
"code": "oral"
}
]
},
"use": "complete",
"patient": {
"reference": "Patient/1"
},
"created": "2014-08-16",
"insurer": {
"identifier": {
"system": "http://www.jurisdiction.org/insurers",
"value": "555123"
}
},
"requestProvider": {
"reference": "Organization/1"
},
"request": {
"identifier": {
"system": "http://happyvalley.com/claim",
"value": "12346"
}
},
"outcome": "complete",
"disposition": "Claim settled as per contract.",
"payeeType": {
"coding": [
{
"system": "http://hl7.org/fhir/payeetype",
"code": "provider"
}
]
},
"item": [
{
"itemSequence": 1,
"adjudication": [
{
"category": {
"coding": [
{
"code": "eligible"
}
]
},
"amount": {
"value": 0.00,
"system": "urn:iso:std:iso:4217",
"code": "USD"
}
},
{
"category": {
"coding": [
{
"code": "benefit"
}
]
},
"amount": {
"value": 0.00,
"system": "urn:iso:std:iso:4217",
"code": "USD"
}
}
]
},
{
"itemSequence": 2,
"adjudication": [
{
"category": {
"coding": [
{
"code": "eligible"
}
]
},
"amount": {
"value": 105.00,
"system": "urn:iso:std:iso:4217",
"code": "USD"
}
},
{
"category": {
"coding": [
{
"code": "eligpercent"
}
]
},
"value": 80.00
},
{
"category": {
"coding": [
{
"code": "benefit"
}
]
},
"amount": {
"value": 84.00,
"system": "urn:iso:std:iso:4217",
"code": "USD"
}
}
]
},
{
"itemSequence": 3,
"adjudication": [
{
"category": {
"coding": [
{
"code": "eligible"
}
]
},
"amount": {
"value": 750.00,
"system": "urn:iso:std:iso:4217",
"code": "USD"
}
},
{
"category": {
"coding": [
{
"code": "eligpercent"
}
]
},
"value": 80.00
},
{
"category": {
"coding": [
{
"code": "benefit"
}
]
},
"amount": {
"value": 600.00,
"system": "urn:iso:std:iso:4217",
"code": "USD"
}
}
],
"detail": [
{
"detailSequence": 1,
"adjudication": [
{
"category": {
"coding": [
{
"code": "eligible"
}
]
},
"amount": {
"value": 750.00,
"system": "urn:iso:std:iso:4217",
"code": "USD"
}
},
{
"category": {
"coding": [
{
"code": "eligpercent"
}
]
},
"value": 80.00
},
{
"category": {
"coding": [
{
"code": "benefit"
}
]
},
"amount": {
"value": 600.00,
"system": "urn:iso:std:iso:4217",
"code": "USD"
}
}
]
},
{
"detailSequence": 2,
"adjudication": [
{
"category": {
"coding": [
{
"code": "eligible"
}
]
},
"amount": {
"value": 0.00,
"system": "urn:iso:std:iso:4217",
"code": "USD"
}
},
{
"category": {
"coding": [
{
"code": "benefit"
}
]
},
"amount": {
"value": 0.00,
"system": "urn:iso:std:iso:4217",
"code": "USD"
}
}
]
}
]
}
],
"addItem": [
{
"itemSequence": [
1
],
"service": {
"coding": [
{
"system": "http://example.org/fhir/oralservicecodes",
"code": "1101"
}
]
},
"modifier": [
{
"coding": [
{
"system": "http://example.org/fhir/modifiers",
"code": "x",
"display": "None"
}
]
}
],
"fee": {
"value": 135.57,
"system": "urn:iso:std:iso:4217",
"code": "USD"
},
"noteNumber": [
101
],
"adjudication": [
{
"category": {
"coding": [
{
"code": "eligible"
}
]
},
"amount": {
"value": 100.00,
"system": "urn:iso:std:iso:4217",
"code": "USD"
}
},
{
"category": {
"coding": [
{
"code": "copay"
}
]
},
"amount": {
"value": 10.00,
"system": "urn:iso:std:iso:4217",
"code": "USD"
}
},
{
"category": {
"coding": [
{
"code": "eligpercent"
}
]
},
"value": 80.00
},
{
"category": {
"coding": [
{
"code": "benefit"
}
]
},
"reason": {
"coding": [
{
"system": "http://hl7.org/fhir/adjudication-reason",
"code": "ar002",
"display": "Plan Limit Reached"
}
]
},
"amount": {
"value": 72.00,
"system": "urn:iso:std:iso:4217",
"code": "USD"
}
}
]
},
{
"itemSequence": [
1
],
"service": {
"coding": [
{
"system": "http://example.org/fhir/oralservicecodes",
"code": "2141",
"display": "Radiograph, bytewing"
}
]
},
"fee": {
"value": 35.57,
"system": "urn:iso:std:iso:4217",
"code": "USD"
},
"adjudication": [
{
"category": {
"coding": [
{
"code": "eligible"
}
]
},
"amount": {
"value": 35.57,
"system": "urn:iso:std:iso:4217",
"code": "USD"
}
},
{
"category": {
"coding": [
{
"code": "eligpercent"
}
]
},
"value": 80.00
},
{
"category": {
"coding": [
{
"code": "benefit"
}
]
},
"amount": {
"value": 28.47,
"system": "urn:iso:std:iso:4217",
"code": "USD"
}
}
]
},
{
"itemSequence": [
3
],
"detailSequence": [
2
],
"service": {
"coding": [
{
"system": "http://example.org/fhir/oralservicecodes",
"code": "expense"
}
]
},
"modifier": [
{
"coding": [
{
"system": "http://example.org/fhir/modifiers",
"code": "x",
"display": "None"
}
]
}
],
"fee": {
"value": 350.00,
"system": "urn:iso:std:iso:4217",
"code": "USD"
},
"noteNumber": [
101
],
"adjudication": [
{
"category": {
"coding": [
{
"code": "eligible"
}
]
},
"amount": {
"value": 350.00,
"system": "urn:iso:std:iso:4217",
"code": "USD"
}
},
{
"category": {
"coding": [
{
"code": "eligpercent"
}
]
},
"value": 80.00
},
{
"category": {
"coding": [
{
"code": "benefit"
}
]
},
"amount": {
"value": 270.00,
"system": "urn:iso:std:iso:4217",
"code": "USD"
}
}
]
}
],
"total": [
{
"category": {
"coding": [
{
"code": "submitted"
}
]
},
"amount": {
"value": 1340.57,
"system": "urn:iso:std:iso:4217",
"code": "USD"
}
},
{
"category": {
"coding": [
{
"code": "benefit"
}
]
},
"amount": {
"value": 1054.47,
"system": "urn:iso:std:iso:4217",
"code": "USD"
}
}
],
"payment": {
"type": {
"coding": [
{
"system": "http://hl7.org/fhir/ex-paymenttype",
"code": "complete"
}
]
},
"date": "2014-08-31",
"amount": {
"value": 100.47,
"system": "urn:iso:std:iso:4217",
"code": "USD"
},
"identifier": {
"system": "http://www.BenefitsInc.com/fhir/paymentidentifier",
"value": "201408-2-15507"
}
},
"processNote": [
{
"number": 101,
"type": "print",
"text": "Package codes are not permitted. Codes replaced by Insurer.",
"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 Mixed Nomative/Trial Use Ballot (v3.3.0-13671) generated on Tue, Apr 3, 2018 12:14+1000. QA Page
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