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| Financial Management Work Group | Maturity Level : N/A | Standards Status : Informative | Compartments : Patient , Practitioner |
Raw JSON ( canonical form + also see JSON Format Specification )
A ClaimResponse demonstrating Payor service code substitutions
{
"resourceType": "ClaimResponse",
"id": "R3503",
"text": {
"status": "generated",
"div": "<div xmlns=\"http://www.w3.org/1999/xhtml\">A human-readable rendering of the ClaimResponse to Claim Oral Average with additional items</div>"
"resourceType" : "ClaimResponse",
"id" : "R3503",
"text" : {
"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\">A human-readable rendering of the ClaimResponse to Claim Oral Average with additional items</div>"
},
"identifier": [
{
"system": "http://www.BenefitsInc.com/fhir/remittance",
"value": "R3503"
}
],
"status": "active",
"type": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/claim-type",
"code": "oral"
}
]
"identifier" : [{
"system" : "http://www.BenefitsInc.com/fhir/remittance",
"value" : "R3503"
}],
"status" : "active",
"type" : {
"coding" : [{
"system" : "http://terminology.hl7.org/CodeSystem/claim-type",
"code" : "oral"
}]
},
"use": "claim",
"patient": {
"reference": "Patient/1"
"use" : "claim",
"patient" : {
"reference" : "Patient/1"
},
"created": "2014-08-16",
"insurer": {
"identifier": {
"system": "http://www.jurisdiction.org/insurers",
"value": "555123"
"created" : "2014-08-16",
"insurer" : {
"identifier" : {
"system" : "http://www.jurisdiction.org/insurers",
"value" : "555123"
}
},
"requestor": {
"reference": "Organization/1"
"requestor" : {
"reference" : "Organization/1"
},
"request": {
"identifier": {
"system": "http://happyvalley.com/claim",
"value": "12346"
"request" : {
"identifier" : {
"system" : "http://happyvalley.com/claim",
"value" : "12346"
}
},
"outcome": "complete",
"disposition": "Claim settled as per contract.",
"payeeType": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/payeetype",
"code": "provider"
"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" : 0.00,
"currency" : "USD"
}
]
},
{
"category" : {
"coding" : [{
"code" : "benefit"
}]
},
"amount" : {
"value" : 0.00,
"currency" : "USD"
}
}]
},
"item": [
{
"itemSequence" : 2,
"adjudication" : [{
"category" : {
"coding" : [{
"code" : "eligible"
}]
},
"amount" : {
"value" : 105.00,
"currency" : "USD"
}
},
{
"itemSequence": 1,
"adjudication": [
{
"category": {
"coding": [
{
"code": "eligible"
}
]
},
"amount": {
"value": 0.00,
"currency": "USD"
}
},
{
"category": {
"coding": [
{
"code": "benefit"
}
]
},
"amount": {
"value": 0.00,
"currency": "USD"
}
}
]
"category" : {
"coding" : [{
"code" : "eligpercent"
}]
},
"quantity" : {
"value" : 80.00
}
},
{
"itemSequence": 2,
"adjudication": [
{
"category": {
"coding": [
{
"code": "eligible"
}
]
},
"amount": {
"value": 105.00,
"currency": "USD"
}
},
{
"category": {
"coding": [
{
"code": "eligpercent"
}
]
},
"value": 80.00
},
{
"category": {
"coding": [
{
"code": "benefit"
}
]
},
"amount": {
"value": 84.00,
"currency": "USD"
}
}
]
"category" : {
"coding" : [{
"code" : "benefit"
}]
},
"amount" : {
"value" : 84.00,
"currency" : "USD"
}
}]
},
{
"itemSequence" : 3,
"adjudication" : [{
"category" : {
"coding" : [{
"code" : "eligible"
}]
},
"amount" : {
"value" : 750.00,
"currency" : "USD"
}
},
{
"itemSequence": 3,
"adjudication": [
{
"category": {
"coding": [
{
"code": "eligible"
}
]
},
"amount": {
"value": 750.00,
"currency": "USD"
}
"category" : {
"coding" : [{
"code" : "eligpercent"
}]
},
"quantity" : {
"value" : 80.00
}
},
{
"category" : {
"coding" : [{
"code" : "benefit"
}]
},
"amount" : {
"value" : 600.00,
"currency" : "USD"
}
}],
"detail" : [{
"detailSequence" : 1,
"adjudication" : [{
"category" : {
"coding" : [{
"code" : "eligible"
}]
},
{
"category": {
"coding": [
{
"code": "eligpercent"
}
]
},
"value": 80.00
"amount" : {
"value" : 750.00,
"currency" : "USD"
}
},
{
"category" : {
"coding" : [{
"code" : "eligpercent"
}]
},
{
"category": {
"coding": [
{
"code": "benefit"
}
]
},
"amount": {
"value": 600.00,
"currency": "USD"
}
"quantity" : {
"value" : 80.00
}
],
"detail": [
{
"detailSequence": 1,
"adjudication": [
{
"category": {
"coding": [
{
"code": "eligible"
}
]
},
"amount": {
"value": 750.00,
"currency": "USD"
}
},
{
"category": {
"coding": [
{
"code": "eligpercent"
}
]
},
"value": 80.00
},
{
"category": {
"coding": [
{
"code": "benefit"
}
]
},
"amount": {
"value": 600.00,
"currency": "USD"
}
}
]
},
{
"category" : {
"coding" : [{
"code" : "benefit"
}]
},
{
"detailSequence": 2,
"adjudication": [
{
"category": {
"coding": [
{
"code": "eligible"
}
]
},
"amount": {
"value": 0.00,
"currency": "USD"
}
},
{
"category": {
"coding": [
{
"code": "benefit"
}
]
},
"amount": {
"value": 0.00,
"currency": "USD"
}
}
]
"amount" : {
"value" : 600.00,
"currency" : "USD"
}
]
}
],
"addItem": [
}]
},
{
"itemSequence": [
1
],
"productOrService": {
"coding": [
{
"system": "http://example.org/fhir/oralservicecodes",
"code": "1101"
}
]
},
"modifier": [
{
"coding": [
{
"system": "http://example.org/fhir/modifiers",
"code": "x",
"display": "None"
}
]
"detailSequence" : 2,
"adjudication" : [{
"category" : {
"coding" : [{
"code" : "eligible"
}]
},
"amount" : {
"value" : 0.00,
"currency" : "USD"
}
],
"net": {
"value": 135.57,
"currency": "USD"
},
"noteNumber": [
101
],
"adjudication": [
{
"category": {
"coding": [
{
"code": "eligible"
}
]
},
"amount": {
"value": 100.00,
"currency": "USD"
}
},
{
"category": {
"coding": [
{
"code": "copay"
}
]
},
"amount": {
"value": 10.00,
"currency": "USD"
}
},
{
"category": {
"coding": [
{
"code": "eligpercent"
}
]
},
"value": 80.00
{
"category" : {
"coding" : [{
"code" : "benefit"
}]
},
{
"category": {
"coding": [
{
"code": "benefit"
}
]
},
"reason": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication-reason",
"code": "ar002",
"display": "Plan Limit Reached"
}
]
},
"amount": {
"value": 72.00,
"currency": "USD"
}
"amount" : {
"value" : 0.00,
"currency" : "USD"
}
]
}]
}]
}],
"addItem" : [{
"itemSequence" : [1],
"productOrService" : {
"coding" : [{
"system" : "http://example.org/fhir/oralservicecodes",
"code" : "1101"
}]
},
"modifier" : [{
"coding" : [{
"system" : "http://example.org/fhir/modifiers",
"code" : "x",
"display" : "None"
}]
}],
"net" : {
"value" : 135.57,
"currency" : "USD"
},
"noteNumber" : [101],
"adjudication" : [{
"category" : {
"coding" : [{
"code" : "eligible"
}]
},
"amount" : {
"value" : 100.00,
"currency" : "USD"
}
},
{
"itemSequence": [
1
],
"productOrService": {
"coding": [
{
"system": "http://example.org/fhir/oralservicecodes",
"code": "2141",
"display": "Radiograph, bytewing"
}
]
"category" : {
"coding" : [{
"code" : "copay"
}]
},
"net": {
"value": 35.57,
"currency": "USD"
"amount" : {
"value" : 10.00,
"currency" : "USD"
}
},
{
"category" : {
"coding" : [{
"code" : "eligpercent"
}]
},
"adjudication": [
{
"category": {
"coding": [
{
"code": "eligible"
}
]
},
"amount": {
"value": 35.57,
"currency": "USD"
}
},
{
"category": {
"coding": [
{
"code": "eligpercent"
}
]
},
"value": 80.00
},
{
"category": {
"coding": [
{
"code": "benefit"
}
]
},
"amount": {
"value": 28.47,
"currency": "USD"
}
}
]
"quantity" : {
"value" : 80.00
}
},
{
"itemSequence": [
3
],
"detailSequence": [
2
],
"productOrService": {
"coding": [
{
"system": "http://example.org/fhir/oralservicecodes",
"code": "expense"
}
]
"category" : {
"coding" : [{
"code" : "benefit"
}]
},
"modifier": [
{
"coding": [
{
"system": "http://example.org/fhir/modifiers",
"code": "x",
"display": "None"
}
]
}
],
"net": {
"value": 350.00,
"currency": "USD"
"reason" : {
"coding" : [{
"system" : "http://terminology.hl7.org/CodeSystem/adjudication-reason",
"code" : "ar002",
"display" : "Plan Limit Reached"
}]
},
"noteNumber": [
101
],
"adjudication": [
{
"category": {
"coding": [
{
"code": "eligible"
}
]
},
"amount": {
"value": 350.00,
"currency": "USD"
}
},
{
"category": {
"coding": [
{
"code": "eligpercent"
}
]
},
"value": 80.00
},
{
"category": {
"coding": [
{
"code": "benefit"
}
]
},
"amount": {
"value": 270.00,
"currency": "USD"
}
}
]
}
],
"total": [
"amount" : {
"value" : 72.00,
"currency" : "USD"
}
}]
},
{
"itemSequence" : [1],
"productOrService" : {
"coding" : [{
"system" : "http://example.org/fhir/oralservicecodes",
"code" : "2141",
"display" : "Radiograph, bytewing"
}]
},
"net" : {
"value" : 35.57,
"currency" : "USD"
},
"adjudication" : [{
"category" : {
"coding" : [{
"code" : "eligible"
}]
},
"amount" : {
"value" : 35.57,
"currency" : "USD"
}
},
{
"category": {
"coding": [
{
"code": "submitted"
}
]
"category" : {
"coding" : [{
"code" : "eligpercent"
}]
},
"amount": {
"value": 1340.57,
"currency": "USD"
"quantity" : {
"value" : 80.00
}
},
{
"category": {
"coding": [
{
"code": "benefit"
}
]
"category" : {
"coding" : [{
"code" : "benefit"
}]
},
"amount": {
"value": 1054.47,
"currency": "USD"
"amount" : {
"value" : 28.47,
"currency" : "USD"
}
}]
},
{
"itemSequence" : [3],
"detailSequence" : [2],
"productOrService" : {
"coding" : [{
"system" : "http://example.org/fhir/oralservicecodes",
"code" : "expense"
}]
},
"modifier" : [{
"coding" : [{
"system" : "http://example.org/fhir/modifiers",
"code" : "x",
"display" : "None"
}]
}],
"net" : {
"value" : 350.00,
"currency" : "USD"
},
"noteNumber" : [101],
"adjudication" : [{
"category" : {
"coding" : [{
"code" : "eligible"
}]
},
"amount" : {
"value" : 350.00,
"currency" : "USD"
}
},
{
"category" : {
"coding" : [{
"code" : "eligpercent"
}]
},
"quantity" : {
"value" : 80.00
}
},
{
"category" : {
"coding" : [{
"code" : "benefit"
}]
},
"amount" : {
"value" : 270.00,
"currency" : "USD"
}
}]
}],
"total" : [{
"category" : {
"coding" : [{
"code" : "submitted"
}]
},
"amount" : {
"value" : 1340.57,
"currency" : "USD"
}
],
"payment": {
"type": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/ex-paymenttype",
"code": "complete"
}
]
},
{
"category" : {
"coding" : [{
"code" : "benefit"
}]
},
"date": "2014-08-31",
"amount": {
"value": 100.47,
"currency": "USD"
"amount" : {
"value" : 1054.47,
"currency" : "USD"
}
}],
"payment" : {
"type" : {
"coding" : [{
"system" : "http://terminology.hl7.org/CodeSystem/ex-paymenttype",
"code" : "complete"
}]
},
"identifier": {
"system": "http://www.BenefitsInc.com/fhir/paymentidentifier",
"value": "201408-2-15507"
"date" : "2014-08-31",
"amount" : {
"value" : 100.47,
"currency" : "USD"
},
"identifier" : {
"system" : "http://www.BenefitsInc.com/fhir/paymentidentifier",
"value" : "201408-2-15507"
}
},
"processNote": [
{
"number": 101,
"type": "print",
"text": "Package codes are not permitted. Codes replaced by Insurer.",
"language": {
"coding": [
{
"system": "urn:ietf:bcp:47",
"code": "en-CA"
}
]
}
"processNote" : [{
"number" : 101,
"type" : {
"coding" : [{
"system" : "http://hl7.org/fhir/note-type",
"code" : "print"
}]
},
"text" : "Package codes are not permitted. Codes replaced by Insurer.",
"language" : {
"coding" : [{
"system" : "urn:ietf:bcp:47",
"code" : "en-CA"
}]
}
]
}]
}
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.
FHIR
®©
HL7.org
2011+.
FHIR
Release
4B
(v4.3.0)
hl7.fhir.r4b.core#4.3.0
R5
hl7.fhir.core#5.0.0-draft-final
generated
on
Sat,
May
28,
2022
12:54+1000.
Wed,
Mar
1,
2023
23:06+1100.
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