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hl7 priv samples ClaimResponse ClaimResponse-R3500.json
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priv/samples/ClaimResponse/ClaimResponse-R3500.json

{"resourceType":"ClaimResponse","id":"R3500","text":{"status":"generated","div":"\u003cdiv xmlns\u003d\"http://www.w3.org/1999/xhtml\"\u003eA human-readable rendering of the ClaimResponse\u003c/div\u003e"},"identifier":[{"system":"http://www.BenefitsInc.com/fhir/remittance","value":"R3500"}],"status":"active","type":{"coding":[{"system":"http://terminology.hl7.org/CodeSystem/claim-type","code":"oral"}]},"subType":{"coding":[{"system":"http://terminology.hl7.org/CodeSystem/ex-claimsubtype","code":"emergency"}]},"use":"claim","patient":{"reference":"Patient/1"},"created":"2014-08-16","insurer":{"identifier":{"system":"http://www.jurisdiction.org/insurers","value":"555123"}},"requestor":{"reference":"Organization/1"},"request":{"reference":"http://www.BenefitsInc.com/fhir/oralhealthclaim/15476332402"},"outcome":"complete","disposition":"Claim settled as per contract.","payeeType":{"coding":[{"system":"http://terminology.hl7.org/CodeSystem/payeetype","code":"provider"}]},"item":[{"itemSequence":1,"adjudication":[{"category":{"coding":[{"code":"eligible"}]},"amount":{"value":135.57,"currency":"USD"}},{"category":{"coding":[{"code":"copay"}]},"amount":{"value":10.00,"currency":"USD"}},{"category":{"coding":[{"code":"eligpercent"}]},"quantity":{"value":80.00}},{"category":{"coding":[{"code":"benefit"}]},"reason":{"coding":[{"system":"http://terminology.hl7.org/CodeSystem/adjudication-reason","code":"ar002","display":"Plan Limit Reached"}]},"amount":{"value":90.47,"currency":"USD"}}]}],"total":[{"category":{"coding":[{"code":"submitted"}]},"amount":{"value":135.57,"currency":"USD"}},{"category":{"coding":[{"code":"benefit"}]},"amount":{"value":90.47,"currency":"USD"}}],"payment":{"type":{"coding":[{"system":"http://terminology.hl7.org/CodeSystem/ex-paymenttype","code":"complete"}]},"date":"2014-08-31","amount":{"value":100.47,"currency":"USD"},"identifier":{"system":"http://www.BenefitsInc.com/fhir/paymentidentifier","value":"201408-2-1569478"}},"meta":{"tag":[{"system":"http://terminology.hl7.org/CodeSystem/v3-ActReason","code":"HTEST","display":"test health data"}]}}