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Claimresponse-example-additem.xml

Example ClaimResponse/R3503 (XML)

Maturity Level : N/A
Responsible Owner: Financial Management Work Group Standards Status : Informative Compartments : Group , Patient , Practitioner

Raw XML ( canonical form + also see XML Format Specification )

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A ClaimResponse demonstrating Payor payer service code substitutions (id = "R3503") 

<?xml version="1.0" encoding="UTF-8"?>



  

  
    
    A human-readable rendering of the ClaimResponse to Claim Oral Average with additional
       items
  

  
    
    
  

  

  
    
      
      
    
  

  

  
    
  

  

  
    
      
      
    
  

  
    
  

  
    
      
      
    
  

  
  
  

  
    
      
      
    
  

  

  

     

    
      
        
          
        
      
      
        
        
      
    
    
      
        
          
        
      
      
        
        
        
    

  

  
     

    
      
        
          
        
      
      
        
        
      
    

    
      
        
          
        
      
      
    

    
      
        
          
        
      
      
        
        
        
    

  

  
     

    
      
        
          
        
      
      
        
        
      
    

    
      
        
          
        
      
      
    

    
      
        
          
        
      
      
        
        
        
    

    
       

      
        
          
            
          
        
        
          
          
        
      

      
        
          
            
          
        
        
      

      
        
          
            
          
        
        
          
          
          
      

    
    
       

      
        
          
            
          
        
        
          
          
        
      

      
        
          
            
          
        
        
          
          
          
      

    
  


  <!--   Pays for a claim package code (1200) with two actual codes (1101, 2141) with adjudication
   details   -->
  
     
    
      
        
        
      
    
    
      
        
        
        
      
    
    
      
      
    
    
    
      
        
          
        
      
      
        
        
      
    

    
      
        
          
        
      
      
        
        
        
    

    
      
        
          
        
      
      
    
    
      
        
          
        
      
      
        
          
          
          
          
        
      
      
        
        
        
    

  
  
     
    
      
        
        
        
      
    
    
      
      
    
    
      
        
          
        
      
      
        
        
      
    

    
      
        
          
        
      
      
    
    
      
        
          
        
      
      
        
        
        
    
  

  <!--   Pays for a claim package code (1200) with two actual codes (1101, 2141) with adjudication
   details   -->
  
     
    
    
      
        
        
      
    
    
      
        
        
        
      
    
    
      
      
    
    
    
      
        
          
        
      
      
        
        
      
    

    
      
        
          
        
      
      
    
    
      
        
          
        
      
      
        
        
        
    

  

  
    
      
        
      
    
    
      
       
     
  
  
  
    
      
        
      
    
    
      
       
     
  

  
  
    
      
        
        
      
      

    

    
      
      
      

    
      
      
      
  

  
    
    
    
    
      
        
        
      
    
    

<ClaimResponse xmlns="http://hl7.org/fhir">
  <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>         <!--   should have paid 100.47   -->        <coding>           <system value="http://terminology.hl7.org/CodeSystem/adjudication-reason"/>           <code value="ar002"/>           <display value="Plan Limit Reached"/>         </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

>

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.