Release 4B Ballot #1
This page is part of the FHIR Specification (v4.1.0: Release 4B Ballot #1). 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-vision-3tier.xml

Financial Management Work Group
Maturity Level: N/A
Standards Status: Informative
Compartments: Patient, Practitioner
Raw XML (canonical form + also see XML Format Specification)
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Primary insurance response to a 3Tier Vision Claim (id = "R3502")
<?xml version="1.0" encoding="UTF-8"?>

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

  <id value="R3502"/> 

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

  <identifier> 
    <system value="http://thebenefitcompany.com/claimresponse"/> 
    <value value="CR6532875367"/> 
  </identifier> 

  <status value="active"/> 

  <type> 
    <coding> 
      <system value="http://terminology.hl7.org/CodeSystem/claim-type"/> 
      <code value="vision"/> 
    </coding> 
  </type> 
  
  <use value="claim"/> 

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

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

  <insurer> 
    <reference value="Organization/2"/> 
  </insurer> 

  <requestor> 
    <reference value="Organization/1"/> 
  </requestor> 

  <request> 
    <identifier>  
      <system value="http://happysight.com/claim"/> 
      <value value="6612346"/> 
    </identifier> 
  </request> 

  <outcome value="complete"/> 

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

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

  <!--   Adjudication details   -->

  <item> 

    <itemSequence value="1"/>  

    <adjudication> 
      <category> 
        <coding> 
          <code value="eligible"/> 
        </coding> 
      </category> 
      <amount> 
        <value value="235.40"/> 
        <currency value="USD"/> 
      </amount> 
    </adjudication> 

    <adjudication> 
      <category> 
        <coding> 
          <code value="copay"/> 
        </coding> 
      </category> 
      <amount> 
        <value value="20.00"/> 
        <currency 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="172.32"/> 
        <currency value="USD"/> 
      </amount>   
    </adjudication> 

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

      <adjudication> 
        <category> 
          <coding> 
            <code value="eligible"/> 
          </coding> 
        </category> 
        <amount> 
          <value value="100.00"/> 
          <currency value="USD"/> 
        </amount> 
      </adjudication> 

      <adjudication> 
        <category> 
          <coding> 
            <code value="copay"/> 
          </coding> 
        </category> 
        <amount> 
          <value value="20.00"/> 
          <currency 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="80.00"/> 
          <currency value="USD"/> 
        </amount>   
      </adjudication> 
    </detail> 
    <detail> 
      <detailSequence value="2"/>  
      <noteNumber value="1"/> 

      <adjudication> 
        <category> 
          <coding> 
            <code value="eligible"/> 
          </coding> 
        </category> 
        <amount> 
          <value value="110.00"/> 
          <currency 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="88.00"/> 
          <currency value="USD"/> 
        </amount>   
      </adjudication> 

      <subDetail> 
        <subDetailSequence value="1"/>  
        <noteNumber value="1"/> 

        <adjudication> 
          <category> 
            <coding> 
              <code value="eligible"/> 
            </coding> 
          </category> 
          <amount> 
            <value value="60.00"/> 
            <currency 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="48.00"/> 
            <currency value="USD"/> 
          </amount>   
        </adjudication> 

      </subDetail> 
      <subDetail> 
        <subDetailSequence value="2"/>  

        <adjudication> 
          <category> 
            <coding> 
              <code value="eligible"/> 
            </coding> 
          </category> 
          <amount> 
            <value value="30.00"/> 
            <currency 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="24.00"/> 
            <currency value="USD"/> 
          </amount>   
        </adjudication> 

      </subDetail> 
      <subDetail> 
        <subDetailSequence value="3"/>  
        <noteNumber value="1"/> 

        <adjudication> 
          <category> 
            <coding> 
              <code value="eligible"/> 
            </coding> 
          </category> 
          <amount> 
            <value value="10.00"/> 
            <currency 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="8.00"/> 
            <currency value="USD"/> 
          </amount>   
        </adjudication> 

      </subDetail> 
    </detail> 
    <detail> 
      <detailSequence value="3"/>  
      <noteNumber value="1"/> 

      <adjudication> 
        <category> 
          <coding> 
            <code value="eligible"/> 
          </coding> 
        </category> 
        <amount> 
          <value value="200.00"/> 
          <currency 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="14.00"/> 
          <currency value="USD"/> 
        </amount>   
      </adjudication> 
    </detail> 

  </item> 

  <total> 
    <category> 
      <coding> 
        <code value="submitted"/> 
      </coding> 
    </category> 
    <amount> 
      <value value="235.40"/> 
      <currency value="USD"/>  
    </amount>  
  </total> 

  <total> 
    <category> 
      <coding> 
        <code value="benefit"/> 
      </coding> 
    </category> 
    <amount> 
      <value value="182.00"/> 
      <currency value="USD"/>  
    </amount>  
  </total> 

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

    <adjustment> 
      <value value="75.00"/> 
      <currency value="USD"/> 
    </adjustment> 

    <adjustmentReason> 
      <coding> 
        <system value="http://terminology.hl7.org/CodeSystem/payment-adjustment-reason"/> 
        <code value="a002"/> 
        <display value="Prior Overpayment"/> 
      </coding> 
    </adjustmentReason> 

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

    <amount> 
      <value value="107.00"/> 
      <currency value="USD"/> 
    </amount>   

    <identifier> 
      <system value="http://thebenefitcompany.com/paymentidentifier"/> 
      <value value="201416-123456"/> 
    </identifier>   
  </payment> 

  <processNote> 
    <number value="1"/> 
    <type value="display"/> 
    <text value="After hours surcharge declined"/> 
    <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.