R4 Ballot #1 (Mixed Normative/Trial use)

This 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

Claimresponse-example-additem.xml

Financial Management Work GroupMaturity Level: N/ABallot Status: InformativeCompartments: Patient, Practitioner

Raw XML (canonical form)

Jump past Narrative

A ClaimResponse demonstrating Payor service code substitutions (id = "R3503")

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

  <id value="R3503"/> 

  <text> 
    <status value="generated"/> 
    <div xmlns="http://www.w3.org/1999/xhtml">A human-readable rendering of the ClaimResponse to Claim Oral Average with additional
       items</div> 
  </text> 

  <identifier> 
    <system value="http://www.BenefitsInc.com/fhir/remittance"/> 
    <value value="R3503"/> 
  </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="Organization/1"/> 
  </requestProvider> 

  <request> 
    <identifier> 
      <system value="http://happyvalley.com/claim"/> 
      <value value="12346"/> 
    </identifier> 
  </request> 

  <outcome value="complete"/> 
  
  <disposition value="Claim settled as per contract."/> 

  <payeeType> 
    <coding> 
      <system value="http://hl7.org/fhir/payeetype"/> 
      <code value="provider"/> 
    </coding> 
  </payeeType> 

  <!--   Adjudication details   -->

  <item>  <!--   Pays for a claim package code with two actual codes with adjudication details   -->

    <itemSequence value="1"/>  

    <adjudication> 
      <category> 
        <coding> 
          <code value="eligible"/> 
        </coding> 
      </category> 
      <amount> 
        <value value="0.00"/> 
        <system value="urn:iso:std:iso:4217"/> 
        <code value="USD"/> 
      </amount> 
    </adjudication> 
    <adjudication> 
      <category> 
        <coding> 
          <code value="benefit"/> 
        </coding> 
      </category> 
      <amount> 
        <value value="0.00"/> 
        <system value="urn:iso:std:iso:4217"/> 
        <code value="USD"/> 
      </amount>   
    </adjudication> 

  </item> 

  <item> 
    <itemSequence value="2"/>  

    <adjudication> 
      <category> 
        <coding> 
          <code value="eligible"/> 
        </coding> 
      </category> 
      <amount> 
        <value value="105.00"/> 
        <system value="urn:iso:std:iso:4217"/> 
        <code value="USD"/> 
      </amount> 
    </adjudication> 

    <adjudication> 
      <category> 
        <coding> 
          <code value="eligpercent"/> 
        </coding> 
      </category> 
      <value value="80.00"/> 
    </adjudication> 

    <adjudication> 
      <category> 
        <coding> 
          <code value="benefit"/> 
        </coding> 
      </category> 
      <amount> 
        <value value="84.00"/> 
        <system value="urn:iso:std:iso:4217"/> 
        <code value="USD"/> 
      </amount>   
    </adjudication> 

  </item> 

  <item> 
    <itemSequence value="3"/>  

    <adjudication> 
      <category> 
        <coding> 
          <code value="eligible"/> 
        </coding> 
      </category> 
      <amount> 
        <value value="750.00"/> 
        <system value="urn:iso:std:iso:4217"/> 
        <code value="USD"/> 
      </amount> 
    </adjudication> 

    <adjudication> 
      <category> 
        <coding> 
          <code value="eligpercent"/> 
        </coding> 
      </category> 
      <value value="80.00"/> 
    </adjudication> 

    <adjudication> 
      <category> 
        <coding> 
          <code value="benefit"/> 
        </coding> 
      </category> 
      <amount> 
        <value value="600.00"/> 
        <system value="urn:iso:std:iso:4217"/> 
        <code value="USD"/> 
      </amount>   
    </adjudication> 

    <detail> 
      <detailSequence value="1"/>  

      <adjudication> 
        <category> 
          <coding> 
            <code value="eligible"/> 
          </coding> 
        </category> 
        <amount> 
          <value value="750.00"/> 
          <system value="urn:iso:std:iso:4217"/> 
          <code value="USD"/> 
        </amount> 
      </adjudication> 

      <adjudication> 
        <category> 
          <coding> 
            <code value="eligpercent"/> 
          </coding> 
        </category> 
        <value value="80.00"/> 
      </adjudication> 

      <adjudication> 
        <category> 
          <coding> 
            <code value="benefit"/> 
          </coding> 
        </category> 
        <amount> 
          <value value="600.00"/> 
          <system value="urn:iso:std:iso:4217"/> 
          <code value="USD"/> 
        </amount>   
      </adjudication> 

    </detail> 
    <detail>   <!--   See the addItem.detail below   -->
      <detailSequence value="2"/>  

      <adjudication> 
        <category> 
          <coding> 
            <code value="eligible"/> 
          </coding> 
        </category> 
        <amount> 
          <value value="0.00"/> 
          <system value="urn:iso:std:iso:4217"/> 
          <code value="USD"/> 
        </amount> 
      </adjudication> 

      <adjudication> 
        <category> 
          <coding> 
            <code value="benefit"/> 
          </coding> 
        </category> 
        <amount> 
          <value value="0.00"/> 
          <system value="urn:iso:std:iso:4217"/> 
          <code value="USD"/> 
        </amount>   
      </adjudication> 

    </detail> 
  </item> 


  <!--   Pays for a claim package code (1200) with two actual codes (1101, 2141) with adjudication
   details   -->
  <addItem> 
    <itemSequence value="1"/>  
    <service> 
      <coding> 
        <system value="http://example.org/fhir/oralservicecodes"/> 
        <code value="1101"/> 
      </coding> 
    </service> 
    <modifier> 
      <coding> 
        <system value="http://example.org/fhir/modifiers"/> 
        <code value="x"/> 
        <display value="None"/> 
      </coding> 
    </modifier> 
    <fee> 
      <value value="135.57"/> 
      <system value="urn:iso:std:iso:4217"/> 
      <code value="USD"/> 
    </fee> 
    <noteNumber value="101"/> 
    <adjudication> 
      <category> 
        <coding> 
          <code value="eligible"/> 
        </coding> 
      </category> 
      <amount> 
        <value value="100.00"/> 
        <system value="urn:iso:std:iso:4217"/> 
        <code value="USD"/> 
      </amount> 
    </adjudication> 

    <adjudication> 
      <category> 
        <coding> 
          <code value="copay"/> 
        </coding> 
      </category> 
      <amount> 
        <value value="10.00"/> 
        <system value="urn:iso:std:iso:4217"/> 
        <code value="USD"/> 
      </amount>   
    </adjudication> 

    <adjudication> 
      <category> 
        <coding> 
          <code value="eligpercent"/> 
        </coding> 
      </category> 
      <value value="80.00"/> 
    </adjudication> 
    <adjudication> 
      <category> 
        <coding> 
          <code value="benefit"/> 
        </coding> 
      </category> 
      <reason> 
        <coding> 
          <system value="http://hl7.org/fhir/adjudication-reason"/> 
          <code value="ar002"/> 
          <display value="Plan Limit Reached"/> 
          <!--   should have paid 100.47   -->
        </coding> 
      </reason> 
      <amount> 
        <value value="72.00"/> 
        <system value="urn:iso:std:iso:4217"/> 
        <code value="USD"/> 
      </amount>   
    </adjudication> 

  </addItem> 
  <addItem> 
    <itemSequence value="1"/>  
    <service> 
      <coding> 
        <system value="http://example.org/fhir/oralservicecodes"/> 
        <code value="2141"/> 
        <display value="Radiograph, bytewing"/> 
      </coding> 
    </service> 
    <fee> 
      <value value="35.57"/> 
      <system value="urn:iso:std:iso:4217"/> 
      <code value="USD"/> 
    </fee> 
    <adjudication> 
      <category> 
        <coding> 
          <code value="eligible"/> 
        </coding> 
      </category> 
      <amount> 
        <value value="35.57"/> 
        <system value="urn:iso:std:iso:4217"/> 
        <code value="USD"/> 
      </amount> 
    </adjudication> 

    <adjudication> 
      <category> 
        <coding> 
          <code value="eligpercent"/> 
        </coding> 
      </category> 
      <value value="80.00"/> 
    </adjudication> 
    <adjudication> 
      <category> 
        <coding> 
          <code value="benefit"/> 
        </coding> 
      </category> 
      <amount> 
        <value value="28.47"/> 
        <system value="urn:iso:std:iso:4217"/> 
        <code value="USD"/> 
      </amount>   
    </adjudication> 
  </addItem> 

  <!--   Pays for a claim package code (1200) with two actual codes (1101, 2141) with adjudication
   details   -->
  <addItem> 
    <itemSequence value="3"/>  
    <detailSequence value="2"/> 
    <service> 
      <coding> 
        <system value="http://example.org/fhir/oralservicecodes"/> 
        <code value="expense"/> 
      </coding> 
    </service> 
    <modifier> 
      <coding> 
        <system value="http://example.org/fhir/modifiers"/> 
        <code value="x"/> 
        <display value="None"/> 
      </coding> 
    </modifier> 
    <fee> 
      <value value="350.00"/> 
      <system value="urn:iso:std:iso:4217"/> 
      <code value="USD"/> 
    </fee> 
    <noteNumber value="101"/> 
    <adjudication> 
      <category> 
        <coding> 
          <code value="eligible"/> 
        </coding> 
      </category> 
      <amount> 
        <value value="350.00"/> 
        <system value="urn:iso:std:iso:4217"/> 
        <code value="USD"/> 
      </amount> 
    </adjudication> 

    <adjudication> 
      <category> 
        <coding> 
          <code value="eligpercent"/> 
        </coding> 
      </category> 
      <value value="80.00"/> 
    </adjudication> 
    <adjudication> 
      <category> 
        <coding> 
          <code value="benefit"/> 
        </coding> 
      </category> 
      <amount> 
        <value value="270.00"/> 
        <system value="urn:iso:std:iso:4217"/> 
        <code value="USD"/> 
      </amount>   
    </adjudication> 

  </addItem> 

  <total> 
    <category> 
      <coding> 
        <code value="submitted"/> 
      </coding> 
    </category> 
    <amount> 
      <value value="1340.57"/> 
      <system value="urn:iso:std:iso:4217"/> 
      <code value="USD"/>  
    </amount>  
  </total> 
  
  <total> 
    <category> 
      <coding> 
        <code value="benefit"/> 
      </coding> 
    </category> 
    <amount> 
      <value value="1054.47"/> 
      <system value="urn:iso:std:iso:4217"/> 
      <code value="USD"/>  
    </amount>  
  </total> 

  <!--   Payment details   -->
  <payment> 
    <type> 
      <coding> 
        <system value="http://hl7.org/fhir/ex-paymenttype"/> 
        <code value="complete"/> 
      </coding> 
    </type>   

    <date value="2014-08-31"/> 

    <amount> 
      <value value="100.47"/> 
      <system value="urn:iso:std:iso:4217"/> 
      <code value="USD"/> 
    </amount>   

    <identifier> 
      <system value="http://www.BenefitsInc.com/fhir/paymentidentifier"/> 
      <value value="201408-2-15507"/> 
    </identifier>   
  </payment> 

  <processNote> 
    <number value="101"/> 
    <type value="print"/> 
    <text value="Package codes are not permitted. Codes replaced by Insurer."/> 
    <language> 
      <coding> 
        <system value="urn:ietf:bcp:47"/> 
        <code value="en-CA"/> 
      </coding> 
    </language> 
  </processNote>   
</ClaimResponse>

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.