type: exampleresource: ClaimResponseexample: claimresponse-example-vision-3tier
ClaimResponse Example: claimresponse-example-vision-3tier
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="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"/>
<subject>
<reference value="Patient/1"/>
</subject>
<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>
<quantity>
<value value="80.00"/>
</quantity>
</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>
<quantity>
<value value="80.00"/>
</quantity>
</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>
<quantity>
<value value="80.00"/>
</quantity>
</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>
<quantity>
<value value="80.00"/>
</quantity>
</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>
<quantity>
<value value="80.00"/>
</quantity>
</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>
<quantity>
<value value="80.00"/>
</quantity>
</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>
<quantity>
<value value="80.00"/>
</quantity>
</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>
<coding>
<system value="http://hl7.org/fhir/note-type"/>
<code value="display"/>
</coding>
</type>
<text value="After hours surcharge declined"/>
<language>
<coding>
<system value="urn:ietf:bcp:47" />
<code value="en-CA" />
</coding>
</language>
</processNote>
</ClaimResponse>