ClaimResponse Example: claimresponse-example

Narrative

A human-readable rendering of the ClaimResponse

Example XML

<ClaimResponse xmlns="http://hl7.org/fhir" xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance" xsi:schemaLocation="http://hl7.org/fhir ../../schema/claimresponse.xsd">

    <id value="R3500"/>

    <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://www.BenefitsInc.com/fhir/remittance"/>
        <value value="R3500"/>
    </identifier>

    <status value="active"/>

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

    <subType>
        <coding>
            <system value="http://terminology.hl7.org/CodeSystem/ex-claimsubtype"/>
            <code value="emergency"/>
        </coding>
    </subType>

    <use value="claim"/>

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

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

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

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

    <request>
        <reference value="http://www.BenefitsInc.com/fhir/oralhealthclaim/15476332402"/>
    </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="135.57"/>
                <currency value="USD"/>
            </amount>
        </adjudication>

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

        <adjudication>
            <category>
                <coding>
                    <code value="eligpercent"/>
                </coding>
            </category>
            <quantity>
                <value value="80.00"/>
            </quantity>
        </adjudication>
        <adjudication>
            <category>
                <coding>
                    <code value="benefit"/>
                </coding>
            </category>
            <reason>
                <coding>
                    <system value="http://terminology.hl7.org/CodeSystem/adjudication-reason"/>
                    <code value="ar002"/>
                    <display value="Plan Limit Reached"/>
                    <!-- should have paid 100.47 -->
                </coding>
            </reason>
            <amount>
                <value value="90.47"/>
                <currency value="USD"/>
            </amount>
        </adjudication>

    </item>

    <total>
        <category>
            <coding>
                <code value="submitted"/>
            </coding>
        </category>
        <amount>
            <value value="135.57"/>
            <currency value="USD"/>
        </amount>
    </total>

    <total>
        <category>
            <coding>
                <code value="benefit"/>
            </coding>
        </category>
        <amount>
            <value value="90.47"/>
            <currency value="USD"/>
        </amount>
    </total>

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

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

        <amount>
            <value value="100.47"/>
            <currency value="USD"/>
        </amount>

        <identifier>
            <system value="http://www.BenefitsInc.com/fhir/paymentidentifier"/>
            <value value="201408-2-1569478"/>
        </identifier>
    </payment>
</ClaimResponse>