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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 )
Primary insurance response to a 3Tier Vision Claim
{
"resourceType": "ClaimResponse",
"id": "R3502",
"text": {
"status": "generated",
"div": "<div xmlns=\"http://www.w3.org/1999/xhtml\">A human-readable rendering of the ClaimResponse</div>"
"resourceType" : "ClaimResponse",
"id" : "R3502",
"text" : {
"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\">A human-readable rendering of the ClaimResponse</div>"
},
"identifier": [
{
"system": "http://thebenefitcompany.com/claimresponse",
"value": "CR6532875367"
}
],
"status": "active",
"type": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/claim-type",
"code": "vision"
}
]
"identifier" : [{
"system" : "http://thebenefitcompany.com/claimresponse",
"value" : "CR6532875367"
}],
"status" : "active",
"type" : {
"coding" : [{
"system" : "http://terminology.hl7.org/CodeSystem/claim-type",
"code" : "vision"
}]
},
"use": "claim",
"patient": {
"reference": "Patient/1"
"use" : "claim",
"patient" : {
"reference" : "Patient/1"
},
"created": "2014-08-16",
"insurer": {
"reference": "Organization/2"
"created" : "2014-08-16",
"insurer" : {
"reference" : "Organization/2"
},
"requestor": {
"reference": "Organization/1"
"requestor" : {
"reference" : "Organization/1"
},
"request": {
"identifier": {
"system": "http://happysight.com/claim",
"value": "6612346"
"request" : {
"identifier" : {
"system" : "http://happysight.com/claim",
"value" : "6612346"
}
},
"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": [
"item" : [{
"itemSequence" : 1,
"adjudication" : [{
"category" : {
"coding" : [{
"code" : "eligible"
}]
},
"amount" : {
"value" : 235.40,
"currency" : "USD"
}
},
{
"itemSequence": 1,
"adjudication": [
{
"category": {
"coding": [
{
"code": "eligible"
}
]
"category" : {
"coding" : [{
"code" : "copay"
}]
},
"amount" : {
"value" : 20.00,
"currency" : "USD"
}
},
{
"category" : {
"coding" : [{
"code" : "eligpercent"
}]
},
"quantity" : {
"value" : 80.00
}
},
{
"category" : {
"coding" : [{
"code" : "benefit"
}]
},
"amount" : {
"value" : 172.32,
"currency" : "USD"
}
}],
"detail" : [{
"detailSequence" : 1,
"noteNumber" : [1],
"adjudication" : [{
"category" : {
"coding" : [{
"code" : "eligible"
}]
},
"amount" : {
"value" : 100.00,
"currency" : "USD"
}
},
{
"category" : {
"coding" : [{
"code" : "copay"
}]
},
"amount" : {
"value" : 20.00,
"currency" : "USD"
}
},
{
"category" : {
"coding" : [{
"code" : "eligpercent"
}]
},
"quantity" : {
"value" : 80.00
}
},
{
"category" : {
"coding" : [{
"code" : "benefit"
}]
},
"amount" : {
"value" : 80.00,
"currency" : "USD"
}
}]
},
{
"detailSequence" : 2,
"noteNumber" : [1],
"adjudication" : [{
"category" : {
"coding" : [{
"code" : "eligible"
}]
},
"amount" : {
"value" : 110.00,
"currency" : "USD"
}
},
{
"category" : {
"coding" : [{
"code" : "eligpercent"
}]
},
"quantity" : {
"value" : 80.00
}
},
{
"category" : {
"coding" : [{
"code" : "benefit"
}]
},
"amount" : {
"value" : 88.00,
"currency" : "USD"
}
}],
"subDetail" : [{
"subDetailSequence" : 1,
"noteNumber" : [1],
"adjudication" : [{
"category" : {
"coding" : [{
"code" : "eligible"
}]
},
"amount": {
"value": 235.40,
"currency": "USD"
"amount" : {
"value" : 60.00,
"currency" : "USD"
}
},
{
"category": {
"coding": [
{
"code": "copay"
}
]
"category" : {
"coding" : [{
"code" : "eligpercent"
}]
},
"amount": {
"value": 20.00,
"currency": "USD"
"quantity" : {
"value" : 80.00
}
},
{
"category": {
"coding": [
{
"code": "eligpercent"
}
]
"category" : {
"coding" : [{
"code" : "benefit"
}]
},
"value": 80.00
"amount" : {
"value" : 48.00,
"currency" : "USD"
}
}]
},
{
"subDetailSequence" : 2,
"adjudication" : [{
"category" : {
"coding" : [{
"code" : "eligible"
}]
},
"amount" : {
"value" : 30.00,
"currency" : "USD"
}
},
{
"category": {
"coding": [
{
"code": "benefit"
}
]
"category" : {
"coding" : [{
"code" : "eligpercent"
}]
},
"amount": {
"value": 172.32,
"currency": "USD"
"quantity" : {
"value" : 80.00
}
}
],
"detail": [
},
{
"detailSequence": 1,
"noteNumber": [
1
],
"adjudication": [
{
"category": {
"coding": [
{
"code": "eligible"
}
]
},
"amount": {
"value": 100.00,
"currency": "USD"
}
},
{
"category": {
"coding": [
{
"code": "copay"
}
]
},
"amount": {
"value": 20.00,
"currency": "USD"
}
},
{
"category": {
"coding": [
{
"code": "eligpercent"
}
]
},
"value": 80.00
},
{
"category": {
"coding": [
{
"code": "benefit"
}
]
},
"amount": {
"value": 80.00,
"currency": "USD"
}
}
]
"category" : {
"coding" : [{
"code" : "benefit"
}]
},
"amount" : {
"value" : 24.00,
"currency" : "USD"
}
}]
},
{
"subDetailSequence" : 3,
"noteNumber" : [1],
"adjudication" : [{
"category" : {
"coding" : [{
"code" : "eligible"
}]
},
"amount" : {
"value" : 10.00,
"currency" : "USD"
}
},
{
"detailSequence": 2,
"noteNumber": [
1
],
"adjudication": [
{
"category": {
"coding": [
{
"code": "eligible"
}
]
},
"amount": {
"value": 110.00,
"currency": "USD"
}
},
{
"category": {
"coding": [
{
"code": "eligpercent"
}
]
},
"value": 80.00
},
{
"category": {
"coding": [
{
"code": "benefit"
}
]
},
"amount": {
"value": 88.00,
"currency": "USD"
}
}
],
"subDetail": [
{
"subDetailSequence": 1,
"noteNumber": [
1
],
"adjudication": [
{
"category": {
"coding": [
{
"code": "eligible"
}
]
},
"amount": {
"value": 60.00,
"currency": "USD"
}
},
{
"category": {
"coding": [
{
"code": "eligpercent"
}
]
},
"value": 80.00
},
{
"category": {
"coding": [
{
"code": "benefit"
}
]
},
"amount": {
"value": 48.00,
"currency": "USD"
}
}
]
},
{
"subDetailSequence": 2,
"adjudication": [
{
"category": {
"coding": [
{
"code": "eligible"
}
]
},
"amount": {
"value": 30.00,
"currency": "USD"
}
},
{
"category": {
"coding": [
{
"code": "eligpercent"
}
]
},
"value": 80.00
},
{
"category": {
"coding": [
{
"code": "benefit"
}
]
},
"amount": {
"value": 24.00,
"currency": "USD"
}
}
]
},
{
"subDetailSequence": 3,
"noteNumber": [
1
],
"adjudication": [
{
"category": {
"coding": [
{
"code": "eligible"
}
]
},
"amount": {
"value": 10.00,
"currency": "USD"
}
},
{
"category": {
"coding": [
{
"code": "eligpercent"
}
]
},
"value": 80.00
},
{
"category": {
"coding": [
{
"code": "benefit"
}
]
},
"amount": {
"value": 8.00,
"currency": "USD"
}
}
]
}
]
"category" : {
"coding" : [{
"code" : "eligpercent"
}]
},
"quantity" : {
"value" : 80.00
}
},
{
"detailSequence": 3,
"noteNumber": [
1
],
"adjudication": [
{
"category": {
"coding": [
{
"code": "eligible"
}
]
},
"amount": {
"value": 200.00,
"currency": "USD"
}
},
{
"category": {
"coding": [
{
"code": "eligpercent"
}
]
},
"value": 80.00
},
{
"category": {
"coding": [
{
"code": "benefit"
}
]
},
"amount": {
"value": 14.00,
"currency": "USD"
}
}
]
}
]
}
],
"total": [
{
"category": {
"coding": [
{
"code": "submitted"
"category" : {
"coding" : [{
"code" : "benefit"
}]
},
"amount" : {
"value" : 8.00,
"currency" : "USD"
}
]
},
"amount": {
"value": 235.40,
"currency": "USD"
}
}]
}]
},
{
"category": {
"coding": [
{
"code": "benefit"
}
]
"detailSequence" : 3,
"noteNumber" : [1],
"adjudication" : [{
"category" : {
"coding" : [{
"code" : "eligible"
}]
},
"amount" : {
"value" : 200.00,
"currency" : "USD"
}
},
"amount": {
"value": 182.00,
"currency": "USD"
}
}
],
"payment": {
"type": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/ex-paymenttype",
"code": "complete"
{
"category" : {
"coding" : [{
"code" : "eligpercent"
}]
},
"quantity" : {
"value" : 80.00
}
]
},
{
"category" : {
"coding" : [{
"code" : "benefit"
}]
},
"amount" : {
"value" : 14.00,
"currency" : "USD"
}
}]
}]
}],
"total" : [{
"category" : {
"coding" : [{
"code" : "submitted"
}]
},
"adjustment": {
"value": 75.00,
"currency": "USD"
"amount" : {
"value" : 235.40,
"currency" : "USD"
}
},
{
"category" : {
"coding" : [{
"code" : "benefit"
}]
},
"adjustmentReason": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/payment-adjustment-reason",
"code": "a002",
"display": "Prior Overpayment"
}
]
"amount" : {
"value" : 182.00,
"currency" : "USD"
}
}],
"payment" : {
"type" : {
"coding" : [{
"system" : "http://terminology.hl7.org/CodeSystem/ex-paymenttype",
"code" : "complete"
}]
},
"date": "2014-08-16",
"amount": {
"value": 107.00,
"currency": "USD"
"adjustment" : {
"value" : 75.00,
"currency" : "USD"
},
"identifier": {
"system": "http://thebenefitcompany.com/paymentidentifier",
"value": "201416-123456"
"adjustmentReason" : {
"coding" : [{
"system" : "http://terminology.hl7.org/CodeSystem/payment-adjustment-reason",
"code" : "a002",
"display" : "Prior Overpayment"
}]
},
"date" : "2014-08-16",
"amount" : {
"value" : 107.00,
"currency" : "USD"
},
"identifier" : {
"system" : "http://thebenefitcompany.com/paymentidentifier",
"value" : "201416-123456"
}
},
"processNote": [
{
"number": 1,
"type": "display",
"text": "After hours surcharge declined",
"language": {
"coding": [
{
"system": "urn:ietf:bcp:47",
"code": "en-CA"
}
]
}
"processNote" : [{
"number" : 1,
"type" : {
"coding" : [{
"system" : "http://hl7.org/fhir/note-type",
"code" : "display"
}]
},
"text" : "After hours surcharge declined",
"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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