Release 4 5

This page is part of the FHIR Specification (v4.0.1: R4 (v5.0.0: R5 - Mixed Normative and STU ) ). This is the current published version in it's permanent home (it will always be available at this URL). The current version which supercedes this version is 5.0.0 . For a full list of available versions, see the Directory of published versions . Page versions: R5 R4B R4

Claimresponse-example-2.xml

Example ClaimResponse/R3501 (XML)

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

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

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A ClaimResponse for a Claim that contains processing errors (id = "R3501") 

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



  

  
    
    
  

  
    
    
  

  

  
    
      
      
    
  

  
  
  
    
  

  

  
    
      
      
    
  

  
    
  

  
    
  

  
  
  
  
  
    
      
      
    
  
  
  
    
    
    
    
      
        
        
      
    
  
  
  
    
  
  
  
  
    
    
    
      
        
        
      
    
  



<ClaimResponse xmlns="http://hl7.org/fhir">
  <id value="R3501"/> 
  <text> 
    <status value="generated"/> 
    <div xmlns="http://www.w3.org/1999/xhtml">A human-readable rendering of the ClaimResponse that demonstrates returning errors</div> 
  </text> 
  <identifier> 
    <system value="http://www.BenefitsInc.com/fhir/remittance"/> 
    <value value="R3501"/> 
  </identifier> 
  <status value="active"/> 
  <type> 
    <coding> 
      <system value="http://terminology.hl7.org/CodeSystem/claim-type"/> 
      <code value="oral"/> 
    </coding> 
  </type> 
  <use value="claim"/> 
  
  <patient>     <reference value="Patient/1"/>   </patient>   <created value="2014-08-16"/>   <insurer>     <identifier>       <system value="http://www.jurisdiction.org/insurers"/>       <value value="555123"/>     </identifier>   </insurer>   <requestor>     <reference value="Practitioner/1"/>   </requestor>   <request>     <reference value="Claim/100156"/>   </request>   <outcome value="error"/> 
  
  <disposition value="Claim could not be processed"/> 
  
  <formCode>     <coding>       <system value="http://terminology.hl7.org/CodeSystem/forms-codes"/>       <code value="2"/>     </coding>   </formCode> 
  
  <processNote>     <number value="1"/>     <type>       <coding>         <system value="http://hl7.org/fhir/note-type"/>         <code value="display"/>       </coding>     </type>     <text value="Invalid claim"/>     <language>       <coding>         <system value="urn:ietf:bcp:47"/>         <code value="en-CA"/>       </coding>     </language>   </processNote> 
  
  <communicationRequest>     <reference value="CommunicationRequest/fm-solicit"/>   </communicationRequest> 
  
    <!--   Detailed error description   -->  <error>     <itemSequence value="3"/>     <detailSequence value="2"/>     <code>       <coding>         <system value="http://terminology.hl7.org/CodeSystem/adjudication-error"/>         <code value="a002"/>       </coding>     </code>   </error> 


</

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.