type: exampleresource: ClaimResponseexample: claimresponse-example-additem
ClaimResponse Example: claimresponse-example-additem
Narrative
A human-readable rendering of the ClaimResponse to Claim Oral Average with additional items
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="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://terminology.hl7.org/CodeSystem/claim-type"/>
<code value="oral"/>
</coding>
</type>
<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>
<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://terminology.hl7.org/CodeSystem/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"/>
<currency value="USD"/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<code value="benefit"/>
</coding>
</category>
<amount>
<value value="0.00"/>
<currency value="USD"/>
</amount>
</adjudication>
</item>
<item>
<itemSequence value="2"/>
<adjudication>
<category>
<coding>
<code value="eligible"/>
</coding>
</category>
<amount>
<value value="105.00"/>
<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>
<amount>
<value value="84.00"/>
<currency value="USD"/>
</amount>
</adjudication>
</item>
<item>
<itemSequence value="3"/>
<adjudication>
<category>
<coding>
<code value="eligible"/>
</coding>
</category>
<amount>
<value value="750.00"/>
<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>
<amount>
<value value="600.00"/>
<currency value="USD"/>
</amount>
</adjudication>
<detail>
<detailSequence value="1"/>
<adjudication>
<category>
<coding>
<code value="eligible"/>
</coding>
</category>
<amount>
<value value="750.00"/>
<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>
<amount>
<value value="600.00"/>
<currency 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"/>
<currency value="USD"/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<code value="benefit"/>
</coding>
</category>
<amount>
<value value="0.00"/>
<currency 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"/>
<productOrService>
<coding>
<system value="http://example.org/fhir/oralservicecodes"/>
<code value="1101"/>
</coding>
</productOrService>
<modifier>
<coding>
<system value="http://example.org/fhir/modifiers"/>
<code value="x"/>
<display value="None"/>
</coding>
</modifier>
<net>
<value value="135.57"/>
<currency value="USD"/>
</net>
<noteNumber value="101"/>
<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="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="72.00"/>
<currency value="USD"/>
</amount>
</adjudication>
</addItem>
<addItem>
<itemSequence value="1"/>
<productOrService>
<coding>
<system value="http://example.org/fhir/oralservicecodes"/>
<code value="2141"/>
<display value="Radiograph, bytewing"/>
</coding>
</productOrService>
<net>
<value value="35.57"/>
<currency value="USD"/>
</net>
<adjudication>
<category>
<coding>
<code value="eligible"/>
</coding>
</category>
<amount>
<value value="35.57"/>
<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>
<amount>
<value value="28.47"/>
<currency 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"/>
<productOrService>
<coding>
<system value="http://example.org/fhir/oralservicecodes"/>
<code value="expense"/>
</coding>
</productOrService>
<modifier>
<coding>
<system value="http://example.org/fhir/modifiers"/>
<code value="x"/>
<display value="None"/>
</coding>
</modifier>
<net>
<value value="350.00"/>
<currency value="USD"/>
</net>
<noteNumber value="101"/>
<adjudication>
<category>
<coding>
<code value="eligible"/>
</coding>
</category>
<amount>
<value value="350.00"/>
<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>
<amount>
<value value="270.00"/>
<currency value="USD"/>
</amount>
</adjudication>
</addItem>
<total>
<category>
<coding>
<code value="submitted"/>
</coding>
</category>
<amount>
<value value="1340.57"/>
<currency value="USD"/>
</amount>
</total>
<total>
<category>
<coding>
<code value="benefit"/>
</coding>
</category>
<amount>
<value value="1054.47"/>
<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="201408-2-15507"/>
</identifier>
</payment>
<processNote>
<number value="101"/>
<type>
<coding>
<system value="http://hl7.org/fhir/note-type"/>
<code value="print"/>
</coding>
</type>
<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>