Release 5 R6 Ballot (2nd Draft)

This page is part of the FHIR Specification (v5.0.0: R5 - STU v6.0.0-ballot2: Release 6 Ballot (2nd Draft) (see Ballot Notes ). This is the The current published version in it's permanent home (it will always be available at this URL). is 5.0.0 . For a full list of available versions, see the Directory of published versions . Page versions: R5 R4B R4

Example ClaimResponse/R3502 (Turtle)

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

Raw Turtle (+ also see Turtle/RDF Format Specification )

Primary insurance response to a 3Tier Vision Claim 

@prefix fhir: <http://hl7.org/fhir/> .
@prefix owl: <http://www.w3.org/2002/07/owl#> .
@prefix rdfs: <http://www.w3.org/2000/01/rdf-schema#> .
@prefix xsd: <http://www.w3.org/2001/XMLSchema#> .

# - resource -------------------------------------------------------------------

[a fhir:ClaimResponse ;
  fhir:nodeRole fhir:treeRoot ;
  fhir:id [ fhir:v "R3502"] ; # 
  fhir:text [
     fhir:status [ fhir:v "generated" ] ;
     fhir:div "<div xmlns=\"http://www.w3.org/1999/xhtml\">A human-readable rendering of the ClaimResponse</div>"
  ] ; # 
  fhir:identifier ( [
     fhir:system [ fhir:v "http://thebenefitcompany.com/claimresponse"^^xsd:anyURI ] ;
     fhir:value [ fhir:v "CR6532875367" ]
  ] ) ; # 
  fhir:status [ fhir:v "active"] ; # 
  fhir:type [
     fhir:coding ( [
       fhir:system [ fhir:v "http://terminology.hl7.org/CodeSystem/claim-type"^^xsd:anyURI ] ;
       fhir:code [ fhir:v "vision" ]
     ] )
  ] ; # 
  fhir:use [ fhir:v "claim"] ; # 
  fhir:patient [
     fhir:reference [ fhir:v "Patient/1" ]
  ] ; # 
  fhir:created [ fhir:v "2014-08-16"^^xsd:date] ; # 
  fhir:insurer [
     fhir:reference [ fhir:v "Organization/2" ]
  ] ; # 
  fhir:requestor [
     fhir:reference [ fhir:v "Organization/1" ]
  ] ; # 
  fhir:request [
     fhir:identifier [
       fhir:system [ fhir:v "http://happysight.com/claim"^^xsd:anyURI ] ;
       fhir:value [ fhir:v "6612346" ]
     ]
  ] ; # 
  fhir:outcome [ fhir:v "complete"] ; # 
  fhir:disposition [ fhir:v "Claim settled as per contract."] ; # 
  fhir:payeeType [
     fhir:coding ( [
       fhir:system [ fhir:v "http://terminology.hl7.org/CodeSystem/payeetype"^^xsd:anyURI ] ;
       fhir:code [ fhir:v "provider" ]
     ] )
  ] ; # 
  fhir:item ( [
     fhir:itemSequence [ fhir:v "1"^^xsd:positiveInteger ] ;
     fhir:adjudication ( [
       fhir:category [
         fhir:coding ( [
           fhir:code [ fhir:v "eligible" ]
         ] )
       ] ;
       fhir:amount [
         fhir:value [ fhir:v "235.40"^^xsd:decimal ] ;
         fhir:currency [ fhir:v "USD" ]
       ]
     ] [
       fhir:category [
         fhir:coding ( [
           fhir:code [ fhir:v "copay" ]
         ] )
       ] ;
       fhir:amount [
         fhir:value [ fhir:v "20.00"^^xsd:decimal ] ;
         fhir:currency [ fhir:v "USD" ]
       ]
     ] [
       fhir:category [
         fhir:coding ( [
           fhir:code [ fhir:v "eligpercent" ]
         ] )
       ] ;
       fhir:quantity [
         fhir:value [ fhir:v "80.00"^^xsd:decimal ]
       ]
     ] [
       fhir:category [
         fhir:coding ( [
           fhir:code [ fhir:v "benefit" ]
         ] )
       ] ;
       fhir:amount [
         fhir:value [ fhir:v "172.32"^^xsd:decimal ] ;
         fhir:currency [ fhir:v "USD" ]
       ]
     ] ) ;
     fhir:detail ( [
       fhir:detailSequence [ fhir:v "1"^^xsd:positiveInteger ] ;
       fhir:noteNumber ( [ fhir:v "1"^^xsd:positiveInteger ] ) ;
       fhir:adjudication ( [
         fhir:category [
           fhir:coding ( [
             fhir:code [ fhir:v "eligible" ]
           ] )
         ] ;
         fhir:amount [
           fhir:value [ fhir:v "100.00"^^xsd:decimal ] ;
           fhir:currency [ fhir:v "USD" ]
         ]
       ] [
         fhir:category [
           fhir:coding ( [
             fhir:code [ fhir:v "copay" ]
           ] )
         ] ;
         fhir:amount [
           fhir:value [ fhir:v "20.00"^^xsd:decimal ] ;
           fhir:currency [ fhir:v "USD" ]
         ]
       ] [
         fhir:category [
           fhir:coding ( [
             fhir:code [ fhir:v "eligpercent" ]
           ] )
         ] ;
         fhir:quantity [
           fhir:value [ fhir:v "80.00"^^xsd:decimal ]
         ]
       ] [
         fhir:category [
           fhir:coding ( [
             fhir:code [ fhir:v "benefit" ]
           ] )
         ] ;
         fhir:amount [
           fhir:value [ fhir:v "80.00"^^xsd:decimal ] ;
           fhir:currency [ fhir:v "USD" ]
         ]
       ] )
     ] [
       fhir:detailSequence [ fhir:v "2"^^xsd:positiveInteger ] ;
       fhir:noteNumber ( [ fhir:v "1"^^xsd:positiveInteger ] ) ;
       fhir:adjudication ( [
         fhir:category [
           fhir:coding ( [
             fhir:code [ fhir:v "eligible" ]
           ] )
         ] ;
         fhir:amount [
           fhir:value [ fhir:v "110.00"^^xsd:decimal ] ;
           fhir:currency [ fhir:v "USD" ]
         ]
       ] [
         fhir:category [
           fhir:coding ( [
             fhir:code [ fhir:v "eligpercent" ]
           ] )
         ] ;
         fhir:quantity [
           fhir:value [ fhir:v "80.00"^^xsd:decimal ]
         ]
       ] [
         fhir:category [
           fhir:coding ( [
             fhir:code [ fhir:v "benefit" ]
           ] )
         ] ;
         fhir:amount [
           fhir:value [ fhir:v "88.00"^^xsd:decimal ] ;
           fhir:currency [ fhir:v "USD" ]
         ]
       ] ) ;
       fhir:subDetail ( [
         fhir:subDetailSequence [ fhir:v "1"^^xsd:positiveInteger ] ;
         fhir:noteNumber ( [ fhir:v "1"^^xsd:positiveInteger ] ) ;
         fhir:adjudication ( [
           fhir:category [
             fhir:coding ( [
               fhir:code [ fhir:v "eligible" ]
             ] )
           ] ;
           fhir:amount [
             fhir:value [ fhir:v "60.00"^^xsd:decimal ] ;
             fhir:currency [ fhir:v "USD" ]
           ]
         ] [
           fhir:category [
             fhir:coding ( [
               fhir:code [ fhir:v "eligpercent" ]
             ] )
           ] ;
           fhir:quantity [
             fhir:value [ fhir:v "80.00"^^xsd:decimal ]
           ]
         ] [
           fhir:category [
             fhir:coding ( [
               fhir:code [ fhir:v "benefit" ]
             ] )
           ] ;
           fhir:amount [
             fhir:value [ fhir:v "48.00"^^xsd:decimal ] ;
             fhir:currency [ fhir:v "USD" ]
           ]
         ] )
       ] [
         fhir:subDetailSequence [ fhir:v "2"^^xsd:positiveInteger ] ;
         fhir:adjudication ( [
           fhir:category [
             fhir:coding ( [
               fhir:code [ fhir:v "eligible" ]
             ] )
           ] ;
           fhir:amount [
             fhir:value [ fhir:v "30.00"^^xsd:decimal ] ;
             fhir:currency [ fhir:v "USD" ]
           ]
         ] [
           fhir:category [
             fhir:coding ( [
               fhir:code [ fhir:v "eligpercent" ]
             ] )
           ] ;
           fhir:quantity [
             fhir:value [ fhir:v "80.00"^^xsd:decimal ]
           ]
         ] [
           fhir:category [
             fhir:coding ( [
               fhir:code [ fhir:v "benefit" ]
             ] )
           ] ;
           fhir:amount [
             fhir:value [ fhir:v "24.00"^^xsd:decimal ] ;
             fhir:currency [ fhir:v "USD" ]
           ]
         ] )
       ] [
         fhir:subDetailSequence [ fhir:v "3"^^xsd:positiveInteger ] ;
         fhir:noteNumber ( [ fhir:v "1"^^xsd:positiveInteger ] ) ;
         fhir:adjudication ( [
           fhir:category [
             fhir:coding ( [
               fhir:code [ fhir:v "eligible" ]
             ] )
           ] ;
           fhir:amount [
             fhir:value [ fhir:v "10.00"^^xsd:decimal ] ;
             fhir:currency [ fhir:v "USD" ]
           ]
         ] [
           fhir:category [
             fhir:coding ( [
               fhir:code [ fhir:v "eligpercent" ]
             ] )
           ] ;
           fhir:quantity [
             fhir:value [ fhir:v "80.00"^^xsd:decimal ]
           ]
         ] [
           fhir:category [
             fhir:coding ( [
               fhir:code [ fhir:v "benefit" ]
             ] )
           ] ;
           fhir:amount [
             fhir:value [ fhir:v "8.00"^^xsd:decimal ] ;
             fhir:currency [ fhir:v "USD" ]
           ]
         ] )
       ] )
     ] [
       fhir:detailSequence [ fhir:v "3"^^xsd:positiveInteger ] ;
       fhir:noteNumber ( [ fhir:v "1"^^xsd:positiveInteger ] ) ;
       fhir:adjudication ( [
         fhir:category [
           fhir:coding ( [
             fhir:code [ fhir:v "eligible" ]
           ] )
         ] ;
         fhir:amount [
           fhir:value [ fhir:v "200.00"^^xsd:decimal ] ;
           fhir:currency [ fhir:v "USD" ]
         ]
       ] [
         fhir:category [
           fhir:coding ( [
             fhir:code [ fhir:v "eligpercent" ]
           ] )
         ] ;
         fhir:quantity [
           fhir:value [ fhir:v "80.00"^^xsd:decimal ]
         ]
       ] [
         fhir:category [
           fhir:coding ( [
             fhir:code [ fhir:v "benefit" ]
           ] )
         ] ;
         fhir:amount [
           fhir:value [ fhir:v "14.00"^^xsd:decimal ] ;
           fhir:currency [ fhir:v "USD" ]
         ]
       ] )
     ] )
  ] ) ; #   Adjudication details  
  fhir:total ( [
     fhir:category [
       fhir:coding ( [
         fhir:code [ fhir:v "submitted" ]
       ] )
     ] ;
     fhir:amount [
       fhir:value [ fhir:v "235.40"^^xsd:decimal ] ;
       fhir:currency [ fhir:v "USD" ]
     ]
  ] [
     fhir:category [
       fhir:coding ( [
         fhir:code [ fhir:v "benefit" ]
       ] )
     ] ;
     fhir:amount [
       fhir:value [ fhir:v "182.00"^^xsd:decimal ] ;
       fhir:currency [ fhir:v "USD" ]
     ]
  ] ) ; # 
  fhir:payment [
     fhir:type [
       fhir:coding ( [
         fhir:system [ fhir:v "http://terminology.hl7.org/CodeSystem/ex-paymenttype"^^xsd:anyURI ] ;
         fhir:code [ fhir:v "complete" ]
       ] )
     ] ;
     fhir:adjustment [
       fhir:value [ fhir:v "75.00"^^xsd:decimal ] ;
       fhir:currency [ fhir:v "USD" ]
     ] ;
     fhir:adjustmentReason [
       fhir:coding ( [
         fhir:system [ fhir:v "http://terminology.hl7.org/CodeSystem/payment-adjustment-reason"^^xsd:anyURI ] ;
         fhir:code [ fhir:v "a002" ] ;
         fhir:display [ fhir:v "Prior Overpayment" ]
       ] )
     ] ;
     fhir:date [ fhir:v "2014-08-16"^^xsd:date ] ;
     fhir:amount [
       fhir:value [ fhir:v "107.00"^^xsd:decimal ] ;
       fhir:currency [ fhir:v "USD" ]
     ] ;
     fhir:identifier [
       fhir:system [ fhir:v "http://thebenefitcompany.com/paymentidentifier"^^xsd:anyURI ] ;
       fhir:value [ fhir:v "201416-123456" ]
     ]
  ] ; #   Payment details  
  fhir:processNote ( [
     fhir:number [ fhir:v "1"^^xsd:positiveInteger ] ;
     fhir:type [
       fhir:coding ( [
         fhir:system [ fhir:v "http://hl7.org/fhir/note-type"^^xsd:anyURI ] ;
         fhir:code [ fhir:v "display" ]
       ] )
     ] ;
     fhir:text [ fhir:v "After hours surcharge declined" ] ;
     fhir:language [
       fhir:coding ( [
         fhir:system [ fhir:v "urn:ietf:bcp:47"^^xsd:anyURI ] ;
         fhir:code [ fhir:v "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.