Release 4B 5

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Claimresponse-example-additem.ttl

Example ClaimResponse/R3503 (Turtle)

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

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

A ClaimResponse demonstrating Payor service code substitutions 

@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 -------------------------------------------------------------------

<http://hl7.org/fhir/ClaimResponse/R3503> a fhir:ClaimResponse;
  fhir:nodeRole fhir:treeRoot;
  fhir:Resource.id [ fhir:value "R3503"];
  fhir:DomainResource.text [
     fhir:Narrative.status [ fhir:value "generated" ];
     fhir:Narrative.div "<div xmlns=\"http://www.w3.org/1999/xhtml\">A human-readable rendering of the ClaimResponse to Claim Oral Average with additional items</div>"
  ];
  fhir:ClaimResponse.identifier [
     fhir:index 0;
     fhir:Identifier.system [ fhir:value "http://www.BenefitsInc.com/fhir/remittance" ];
     fhir:Identifier.value [ fhir:value "R3503" ]
  ];
  fhir:ClaimResponse.status [ fhir:value "active"];
  fhir:ClaimResponse.type [
     fhir:CodeableConcept.coding [
       fhir:index 0;
       fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/claim-type" ];
       fhir:Coding.code [ fhir:value "oral" ]
     ]
  ];
  fhir:ClaimResponse.use [ fhir:value "claim"];
  fhir:ClaimResponse.patient [
     fhir:link <http://hl7.org/fhir/Patient/1>;
     fhir:Reference.reference [ fhir:value "Patient/1" ]
  ];
  fhir:ClaimResponse.created [ fhir:value "2014-08-16"^^xsd:date];
  fhir:ClaimResponse.insurer [
     fhir:Reference.identifier [
       fhir:Identifier.system [ fhir:value "http://www.jurisdiction.org/insurers" ];
       fhir:Identifier.value [ fhir:value "555123" ]
     ]
  ];
  fhir:ClaimResponse.requestor [
     fhir:link <http://hl7.org/fhir/Organization/1>;
     fhir:Reference.reference [ fhir:value "Organization/1" ]
  ];
  fhir:ClaimResponse.request [
     fhir:Reference.identifier [
       fhir:Identifier.system [ fhir:value "http://happyvalley.com/claim" ];
       fhir:Identifier.value [ fhir:value "12346" ]
     ]
  ];
  fhir:ClaimResponse.outcome [ fhir:value "complete"];
  fhir:ClaimResponse.disposition [ fhir:value "Claim settled as per contract."];
  fhir:ClaimResponse.payeeType [
     fhir:CodeableConcept.coding [
       fhir:index 0;
       fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/payeetype" ];
       fhir:Coding.code [ fhir:value "provider" ]

[a fhir:ClaimResponse ;
  fhir:nodeRole fhir:treeRoot ;
  fhir:id [ fhir:v "R3503"] ; # 
  fhir:text [
     fhir:status [ fhir:v "generated" ] ;
     fhir:div "<div xmlns=\"http://www.w3.org/1999/xhtml\">A human-readable rendering of the ClaimResponse to Claim Oral Average with additional items</div>"
  ] ; # 
  fhir:identifier ( [
     fhir:system [ fhir:v "http://www.BenefitsInc.com/fhir/remittance"^^xsd:anyURI ] ;
     fhir:value [ fhir:v "R3503" ]
  ] ) ; # 
  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 "oral" ]
     ] )
  ] ; # 
  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:identifier [
       fhir:system [ fhir:v "http://www.jurisdiction.org/insurers"^^xsd:anyURI ] ;
       fhir:value [ fhir:v "555123" ]

     ]
  ];
  fhir:ClaimResponse.item [
     fhir:index 0;
     fhir:ClaimResponse.item.itemSequence [ fhir:value "1"^^xsd:positiveInteger ];
     fhir:ClaimResponse.item.adjudication [
       fhir:index 0;
       fhir:ClaimResponse.item.adjudication.category [
         fhir:CodeableConcept.coding [
           fhir:index 0;
           fhir:Coding.code [ fhir:value "eligible" ]
         ]
       ];
       fhir:ClaimResponse.item.adjudication.amount [
         fhir:Money.value [ fhir:value "0.00"^^xsd:decimal ];
         fhir:Money.currency [ fhir:value "USD" ]
       ]
     ], [
       fhir:index 1;
       fhir:ClaimResponse.item.adjudication.category [
         fhir:CodeableConcept.coding [
           fhir:index 0;
           fhir:Coding.code [ fhir:value "benefit" ]
         ]
       ];
       fhir:ClaimResponse.item.adjudication.amount [
         fhir:Money.value [ fhir:value "0.00"^^xsd:decimal ];
         fhir:Money.currency [ fhir:value "USD" ]
       ]

  ] ; # 
  fhir:requestor [
     fhir:reference [ fhir:v "Organization/1" ]
  ] ; # 
  fhir:request [
     fhir:identifier [
       fhir:system [ fhir:v "http://happyvalley.com/claim"^^xsd:anyURI ] ;
       fhir:value [ fhir:v "12346" ]

     ]
  ], [
     fhir:index 1;
     fhir:ClaimResponse.item.itemSequence [ fhir:value "2"^^xsd:positiveInteger ];
     fhir:ClaimResponse.item.adjudication [
       fhir:index 0;
       fhir:ClaimResponse.item.adjudication.category [
         fhir:CodeableConcept.coding [
           fhir:index 0;
           fhir:Coding.code [ fhir:value "eligible" ]
         ]
       ];
       fhir:ClaimResponse.item.adjudication.amount [
         fhir:Money.value [ fhir:value "105.00"^^xsd:decimal ];
         fhir:Money.currency [ fhir:value "USD" ]

  ] ; # 
  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 ] ; #   Pays for a claim package code with two actual codes with adjudication details  
     fhir:adjudication ( [
       fhir:category [
         fhir:coding ( [
           fhir:code [ fhir:v "eligible" ]
         ] )
       ] ;
       fhir:amount [
         fhir:value [ fhir:v "0.00"^^xsd:decimal ] ;
         fhir:currency [ fhir:v "USD" ]

       ]
     ], [
       fhir:index 1;
       fhir:ClaimResponse.item.adjudication.category [
         fhir:CodeableConcept.coding [
           fhir:index 0;
           fhir:Coding.code [ fhir:value "eligpercent" ]
         ]
       ];
       fhir:ClaimResponse.item.adjudication.value [ fhir:value "80.00"^^xsd:decimal ]
     ], [
       fhir:index 2;
       fhir:ClaimResponse.item.adjudication.category [
         fhir:CodeableConcept.coding [
           fhir:index 0;
           fhir:Coding.code [ fhir:value "benefit" ]
         ]
       ];
       fhir:ClaimResponse.item.adjudication.amount [
         fhir:Money.value [ fhir:value "84.00"^^xsd:decimal ];
         fhir:Money.currency [ fhir:value "USD" ]

     ] [
       fhir:category [
         fhir:coding ( [
           fhir:code [ fhir:v "benefit" ]
         ] )
       ] ;
       fhir:amount [
         fhir:value [ fhir:v "0.00"^^xsd:decimal ] ;
         fhir:currency [ fhir:v "USD" ]

       ]
     ]
  ], [
     fhir:index 2;
     fhir:ClaimResponse.item.itemSequence [ fhir:value "3"^^xsd:positiveInteger ];
     fhir:ClaimResponse.item.adjudication [
       fhir:index 0;
       fhir:ClaimResponse.item.adjudication.category [
         fhir:CodeableConcept.coding [
           fhir:index 0;
           fhir:Coding.code [ fhir:value "eligible" ]
         ]
       ];
       fhir:ClaimResponse.item.adjudication.amount [
         fhir:Money.value [ fhir:value "750.00"^^xsd:decimal ];
         fhir:Money.currency [ fhir:value "USD" ]

     ] )
  ] [
     fhir:itemSequence [ fhir:v "2"^^xsd:positiveInteger ] ;
     fhir:adjudication ( [
       fhir:category [
         fhir:coding ( [
           fhir:code [ fhir:v "eligible" ]
         ] )
       ] ;
       fhir:amount [
         fhir:value [ fhir:v "105.00"^^xsd:decimal ] ;
         fhir:currency [ fhir:v "USD" ]

       ]
     ], [
       fhir:index 1;
       fhir:ClaimResponse.item.adjudication.category [
         fhir:CodeableConcept.coding [
           fhir:index 0;
           fhir:Coding.code [ fhir:value "eligpercent" ]
         ]
       ];
       fhir:ClaimResponse.item.adjudication.value [ fhir:value "80.00"^^xsd:decimal ]
     ], [
       fhir:index 2;
       fhir:ClaimResponse.item.adjudication.category [
         fhir:CodeableConcept.coding [
           fhir:index 0;
           fhir:Coding.code [ fhir:value "benefit" ]
         ]
       ];
       fhir:ClaimResponse.item.adjudication.amount [
         fhir:Money.value [ fhir:value "600.00"^^xsd:decimal ];
         fhir:Money.currency [ fhir:value "USD" ]

     ] [
       fhir:category [
         fhir:coding ( [
           fhir:code [ fhir:v "eligpercent" ]
         ] )
       ] ;
       fhir:quantity [
         fhir:value [ fhir:v "80.00"^^xsd:decimal ]

       ]
     ];
     fhir:ClaimResponse.item.detail [
       fhir:index 0;
       fhir:ClaimResponse.item.detail.detailSequence [ fhir:value "1"^^xsd:positiveInteger ];
       fhir:ClaimResponse.item.detail.adjudication [
         fhir:index 0;
         fhir:ClaimResponse.item.adjudication.category [
           fhir:CodeableConcept.coding [
             fhir:index 0;
             fhir:Coding.code [ fhir:value "eligible" ]
           ]
         ];
         fhir:ClaimResponse.item.adjudication.amount [
           fhir:Money.value [ fhir:value "750.00"^^xsd:decimal ];
           fhir:Money.currency [ fhir:value "USD" ]
         ]
       ], [
         fhir:index 1;
         fhir:ClaimResponse.item.adjudication.category [
           fhir:CodeableConcept.coding [
             fhir:index 0;
             fhir:Coding.code [ fhir:value "eligpercent" ]
           ]
         ];
         fhir:ClaimResponse.item.adjudication.value [ fhir:value "80.00"^^xsd:decimal ]
       ], [
         fhir:index 2;
         fhir:ClaimResponse.item.adjudication.category [
           fhir:CodeableConcept.coding [
             fhir:index 0;
             fhir:Coding.code [ fhir:value "benefit" ]
           ]
         ];
         fhir:ClaimResponse.item.adjudication.amount [
           fhir:Money.value [ fhir:value "600.00"^^xsd:decimal ];
           fhir:Money.currency [ fhir:value "USD" ]
         ]

     ] [
       fhir:category [
         fhir:coding ( [
           fhir:code [ fhir:v "benefit" ]
         ] )
       ] ;
       fhir:amount [
         fhir:value [ fhir:v "84.00"^^xsd:decimal ] ;
         fhir:currency [ fhir:v "USD" ]

       ]
     ], [
       fhir:index 1;
       fhir:ClaimResponse.item.detail.detailSequence [ fhir:value "2"^^xsd:positiveInteger ];
       fhir:ClaimResponse.item.detail.adjudication [
         fhir:index 0;
         fhir:ClaimResponse.item.adjudication.category [
           fhir:CodeableConcept.coding [
             fhir:index 0;
             fhir:Coding.code [ fhir:value "eligible" ]
           ]
         ];
         fhir:ClaimResponse.item.adjudication.amount [
           fhir:Money.value [ fhir:value "0.00"^^xsd:decimal ];
           fhir:Money.currency [ fhir:value "USD" ]
         ]
       ], [
         fhir:index 1;
         fhir:ClaimResponse.item.adjudication.category [
           fhir:CodeableConcept.coding [
             fhir:index 0;
             fhir:Coding.code [ fhir:value "benefit" ]
           ]
         ];
         fhir:ClaimResponse.item.adjudication.amount [
           fhir:Money.value [ fhir:value "0.00"^^xsd:decimal ];
           fhir:Money.currency [ fhir:value "USD" ]
         ]

     ] )
  ] [
     fhir:itemSequence [ fhir:v "3"^^xsd:positiveInteger ] ;
     fhir:adjudication ( [
       fhir:category [
         fhir:coding ( [
           fhir:code [ fhir:v "eligible" ]
         ] )
       ] ;
       fhir:amount [
         fhir:value [ fhir:v "750.00"^^xsd:decimal ] ;
         fhir:currency [ fhir:v "USD" ]

       ]
     ]
  ];
  fhir:ClaimResponse.addItem [
     fhir:index 0;
     fhir:ClaimResponse.addItem.itemSequence [
       fhir:value "1"^^xsd:positiveInteger;
       fhir:index 0
     ];
     fhir:ClaimResponse.addItem.productOrService [
       fhir:CodeableConcept.coding [
         fhir:index 0;
         fhir:Coding.system [ fhir:value "http://example.org/fhir/oralservicecodes" ];
         fhir:Coding.code [ fhir:value "1101" ]

     ] [
       fhir:category [
         fhir:coding ( [
           fhir:code [ fhir:v "eligpercent" ]
         ] )
       ] ;
       fhir:quantity [
         fhir:value [ fhir:v "80.00"^^xsd:decimal ]

       ]
     ];
     fhir:ClaimResponse.addItem.modifier [
       fhir:index 0;
       fhir:CodeableConcept.coding [
         fhir:index 0;
         fhir:Coding.system [ fhir:value "http://example.org/fhir/modifiers" ];
         fhir:Coding.code [ fhir:value "x" ];
         fhir:Coding.display [ fhir:value "None" ]

     ] [
       fhir:category [
         fhir:coding ( [
           fhir:code [ fhir:v "benefit" ]
         ] )
       ] ;
       fhir:amount [
         fhir:value [ fhir:v "600.00"^^xsd:decimal ] ;
         fhir:currency [ fhir:v "USD" ]

       ]
     ];
     fhir:ClaimResponse.addItem.net [
       fhir:Money.value [ fhir:value "135.57"^^xsd:decimal ];
       fhir:Money.currency [ fhir:value "USD" ]
     ];
     fhir:ClaimResponse.addItem.noteNumber [
       fhir:value "101"^^xsd:positiveInteger;
       fhir:index 0
     ];
     fhir:ClaimResponse.addItem.adjudication [
       fhir:index 0;
       fhir:ClaimResponse.item.adjudication.category [
         fhir:CodeableConcept.coding [
           fhir:index 0;
           fhir:Coding.code [ fhir:value "eligible" ]

     ] ) ;
     fhir:detail ( [
       fhir:detailSequence [ fhir:v "1"^^xsd:positiveInteger ] ;
       fhir:adjudication ( [
         fhir:category [
           fhir:coding ( [
             fhir:code [ fhir:v "eligible" ]
           ] )
         ] ;
         fhir:amount [
           fhir:value [ fhir:v "750.00"^^xsd:decimal ] ;
           fhir:currency [ fhir:v "USD" ]

         ]
       ];
       fhir:ClaimResponse.item.adjudication.amount [
         fhir:Money.value [ fhir:value "100.00"^^xsd:decimal ];
         fhir:Money.currency [ fhir:value "USD" ]
       ]
     ], [
       fhir:index 1;
       fhir:ClaimResponse.item.adjudication.category [
         fhir:CodeableConcept.coding [
           fhir:index 0;
           fhir:Coding.code [ fhir:value "copay" ]

       ] [
         fhir:category [
           fhir:coding ( [
             fhir:code [ fhir:v "eligpercent" ]
           ] )
         ] ;
         fhir:quantity [
           fhir:value [ fhir:v "80.00"^^xsd:decimal ]

         ]
       ];
       fhir:ClaimResponse.item.adjudication.amount [
         fhir:Money.value [ fhir:value "10.00"^^xsd:decimal ];
         fhir:Money.currency [ fhir:value "USD" ]
       ]
     ], [
       fhir:index 2;
       fhir:ClaimResponse.item.adjudication.category [
         fhir:CodeableConcept.coding [
           fhir:index 0;
           fhir:Coding.code [ fhir:value "eligpercent" ]

       ] [
         fhir:category [
           fhir:coding ( [
             fhir:code [ fhir:v "benefit" ]
           ] )
         ] ;
         fhir:amount [
           fhir:value [ fhir:v "600.00"^^xsd:decimal ] ;
           fhir:currency [ fhir:v "USD" ]

         ]
       ];
       fhir:ClaimResponse.item.adjudication.value [ fhir:value "80.00"^^xsd:decimal ]
     ], [
       fhir:index 3;
       fhir:ClaimResponse.item.adjudication.category [
         fhir:CodeableConcept.coding [
           fhir:index 0;
           fhir:Coding.code [ fhir:value "benefit" ]

       ] )
     ] [
       fhir:detailSequence [ fhir:v "2"^^xsd:positiveInteger ] ; #   See the addItem.detail below  
       fhir:adjudication ( [
         fhir:category [
           fhir:coding ( [
             fhir:code [ fhir:v "eligible" ]
           ] )
         ] ;
         fhir:amount [
           fhir:value [ fhir:v "0.00"^^xsd:decimal ] ;
           fhir:currency [ fhir:v "USD" ]

         ]
       ];
       fhir:ClaimResponse.item.adjudication.reason [
         fhir:CodeableConcept.coding [
           fhir:index 0;
           fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/adjudication-reason" ];
           fhir:Coding.code [ fhir:value "ar002" ];
           fhir:Coding.display [ fhir:value "Plan Limit Reached" ]

       ] [
         fhir:category [
           fhir:coding ( [
             fhir:code [ fhir:v "benefit" ]
           ] )
         ] ;
         fhir:amount [
           fhir:value [ fhir:v "0.00"^^xsd:decimal ] ;
           fhir:currency [ fhir:v "USD" ]

         ]
       ];
       fhir:ClaimResponse.item.adjudication.amount [
         fhir:Money.value [ fhir:value "72.00"^^xsd:decimal ];
         fhir:Money.currency [ fhir:value "USD" ]

       ] )
     ] )
  ] ) ; #   Adjudication details  
  fhir:addItem ( [
     fhir:itemSequence ( [ fhir:v "1"^^xsd:positiveInteger ] ) ;
     fhir:productOrService [
       fhir:coding ( [
         fhir:system [ fhir:v "http://example.org/fhir/oralservicecodes"^^xsd:anyURI ] ;
         fhir:code [ fhir:v "1101" ]
       ] )
     ] ;
     fhir:modifier ( [
       fhir:coding ( [
         fhir:system [ fhir:v "http://example.org/fhir/modifiers"^^xsd:anyURI ] ;
         fhir:code [ fhir:v "x" ] ;
         fhir:display [ fhir:v "None" ]
       ] )
     ] ) ;
     fhir:net [
       fhir:value [ fhir:v "135.57"^^xsd:decimal ] ;
       fhir:currency [ fhir:v "USD" ]
     ] ;
     fhir:noteNumber ( [ fhir:v "101"^^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:index 1;
     fhir:ClaimResponse.addItem.itemSequence [
       fhir:value "1"^^xsd:positiveInteger;
       fhir:index 0
     ];
     fhir:ClaimResponse.addItem.productOrService [
       fhir:CodeableConcept.coding [
         fhir:index 0;
         fhir:Coding.system [ fhir:value "http://example.org/fhir/oralservicecodes" ];
         fhir:Coding.code [ fhir:value "2141" ];
         fhir:Coding.display [ fhir:value "Radiograph, bytewing" ]

     ] [
       fhir:category [
         fhir:coding ( [
           fhir:code [ fhir:v "copay" ]
         ] )
       ] ;
       fhir:amount [
         fhir:value [ fhir:v "10.00"^^xsd:decimal ] ;
         fhir:currency [ fhir:v "USD" ]

       ]
     ];
     fhir:ClaimResponse.addItem.net [
       fhir:Money.value [ fhir:value "35.57"^^xsd:decimal ];
       fhir:Money.currency [ fhir:value "USD" ]
     ];
     fhir:ClaimResponse.addItem.adjudication [
       fhir:index 0;
       fhir:ClaimResponse.item.adjudication.category [
         fhir:CodeableConcept.coding [
           fhir:index 0;
           fhir:Coding.code [ fhir:value "eligible" ]
         ]
       ];
       fhir:ClaimResponse.item.adjudication.amount [
         fhir:Money.value [ fhir:value "35.57"^^xsd:decimal ];
         fhir:Money.currency [ fhir:value "USD" ]

     ] [
       fhir:category [
         fhir:coding ( [
           fhir:code [ fhir:v "eligpercent" ]
         ] )
       ] ;
       fhir:quantity [
         fhir:value [ fhir:v "80.00"^^xsd:decimal ]

       ]
     ], [
       fhir:index 1;
       fhir:ClaimResponse.item.adjudication.category [
         fhir:CodeableConcept.coding [
           fhir:index 0;
           fhir:Coding.code [ fhir:value "eligpercent" ]
         ]
       ];
       fhir:ClaimResponse.item.adjudication.value [ fhir:value "80.00"^^xsd:decimal ]
     ], [
       fhir:index 2;
       fhir:ClaimResponse.item.adjudication.category [
         fhir:CodeableConcept.coding [
           fhir:index 0;
           fhir:Coding.code [ fhir:value "benefit" ]
         ]
       ];
       fhir:ClaimResponse.item.adjudication.amount [
         fhir:Money.value [ fhir:value "28.47"^^xsd:decimal ];
         fhir:Money.currency [ fhir:value "USD" ]

     ] [
       fhir:category [
         fhir:coding ( [
           fhir:code [ fhir:v "benefit" ]
         ] )
       ] ;
       fhir:reason [
         fhir:coding ( [
           fhir:system [ fhir:v "http://terminology.hl7.org/CodeSystem/adjudication-reason"^^xsd:anyURI ] ;
           fhir:code [ fhir:v "ar002" ] ;
           fhir:display [ fhir:v "Plan Limit Reached" ]
         ] ) #   should have paid 100.47  
       ] ;
       fhir:amount [
         fhir:value [ fhir:v "72.00"^^xsd:decimal ] ;
         fhir:currency [ fhir:v "USD" ]

       ]
     ]
  ], [
     fhir:index 2;
     fhir:ClaimResponse.addItem.itemSequence [
       fhir:value "3"^^xsd:positiveInteger;
       fhir:index 0
     ];
     fhir:ClaimResponse.addItem.detailSequence [
       fhir:value "2"^^xsd:positiveInteger;
       fhir:index 0
     ];
     fhir:ClaimResponse.addItem.productOrService [
       fhir:CodeableConcept.coding [
         fhir:index 0;
         fhir:Coding.system [ fhir:value "http://example.org/fhir/oralservicecodes" ];
         fhir:Coding.code [ fhir:value "expense" ]

     ] )
  ] [
     fhir:itemSequence ( [ fhir:v "1"^^xsd:positiveInteger ] ) ;
     fhir:productOrService [
       fhir:coding ( [
         fhir:system [ fhir:v "http://example.org/fhir/oralservicecodes"^^xsd:anyURI ] ;
         fhir:code [ fhir:v "2141" ] ;
         fhir:display [ fhir:v "Radiograph, bytewing" ]
       ] )
     ] ;
     fhir:net [
       fhir:value [ fhir:v "35.57"^^xsd:decimal ] ;
       fhir:currency [ fhir:v "USD" ]
     ] ;
     fhir:adjudication ( [
       fhir:category [
         fhir:coding ( [
           fhir:code [ fhir:v "eligible" ]
         ] )
       ] ;
       fhir:amount [
         fhir:value [ fhir:v "35.57"^^xsd:decimal ] ;
         fhir:currency [ fhir:v "USD" ]

       ]
     ];
     fhir:ClaimResponse.addItem.modifier [
       fhir:index 0;
       fhir:CodeableConcept.coding [
         fhir:index 0;
         fhir:Coding.system [ fhir:value "http://example.org/fhir/modifiers" ];
         fhir:Coding.code [ fhir:value "x" ];
         fhir:Coding.display [ fhir:value "None" ]

     ] [
       fhir:category [
         fhir:coding ( [
           fhir:code [ fhir:v "eligpercent" ]
         ] )
       ] ;
       fhir:quantity [
         fhir:value [ fhir:v "80.00"^^xsd:decimal ]

       ]
     ];
     fhir:ClaimResponse.addItem.net [
       fhir:Money.value [ fhir:value "350.00"^^xsd:decimal ];
       fhir:Money.currency [ fhir:value "USD" ]
     ];
     fhir:ClaimResponse.addItem.noteNumber [
       fhir:value "101"^^xsd:positiveInteger;
       fhir:index 0
     ];
     fhir:ClaimResponse.addItem.adjudication [
       fhir:index 0;
       fhir:ClaimResponse.item.adjudication.category [
         fhir:CodeableConcept.coding [
           fhir:index 0;
           fhir:Coding.code [ fhir:value "eligible" ]
         ]
       ];
       fhir:ClaimResponse.item.adjudication.amount [
         fhir:Money.value [ fhir:value "350.00"^^xsd:decimal ];
         fhir:Money.currency [ fhir:value "USD" ]

     ] [
       fhir:category [
         fhir:coding ( [
           fhir:code [ fhir:v "benefit" ]
         ] )
       ] ;
       fhir:amount [
         fhir:value [ fhir:v "28.47"^^xsd:decimal ] ;
         fhir:currency [ fhir:v "USD" ]

       ]
     ], [
       fhir:index 1;
       fhir:ClaimResponse.item.adjudication.category [
         fhir:CodeableConcept.coding [
           fhir:index 0;
           fhir:Coding.code [ fhir:value "eligpercent" ]
         ]
       ];
       fhir:ClaimResponse.item.adjudication.value [ fhir:value "80.00"^^xsd:decimal ]
     ], [
       fhir:index 2;
       fhir:ClaimResponse.item.adjudication.category [
         fhir:CodeableConcept.coding [
           fhir:index 0;
           fhir:Coding.code [ fhir:value "benefit" ]
         ]
       ];
       fhir:ClaimResponse.item.adjudication.amount [
         fhir:Money.value [ fhir:value "270.00"^^xsd:decimal ];
         fhir:Money.currency [ fhir:value "USD" ]

     ] )
  ] [
     fhir:itemSequence ( [ fhir:v "3"^^xsd:positiveInteger ] ) ;
     fhir:detailSequence ( [ fhir:v "2"^^xsd:positiveInteger ] ) ;
     fhir:productOrService [
       fhir:coding ( [
         fhir:system [ fhir:v "http://example.org/fhir/oralservicecodes"^^xsd:anyURI ] ;
         fhir:code [ fhir:v "expense" ]
       ] )
     ] ;
     fhir:modifier ( [
       fhir:coding ( [
         fhir:system [ fhir:v "http://example.org/fhir/modifiers"^^xsd:anyURI ] ;
         fhir:code [ fhir:v "x" ] ;
         fhir:display [ fhir:v "None" ]
       ] )
     ] ) ;
     fhir:net [
       fhir:value [ fhir:v "350.00"^^xsd:decimal ] ;
       fhir:currency [ fhir:v "USD" ]
     ] ;
     fhir:noteNumber ( [ fhir:v "101"^^xsd:positiveInteger ] ) ;
     fhir:adjudication ( [
       fhir:category [
         fhir:coding ( [
           fhir:code [ fhir:v "eligible" ]
         ] )
       ] ;
       fhir:amount [
         fhir:value [ fhir:v "350.00"^^xsd:decimal ] ;
         fhir:currency [ fhir:v "USD" ]

       ]
     ]
  ];
  fhir:ClaimResponse.total [
     fhir:index 0;
     fhir:ClaimResponse.total.category [
       fhir:CodeableConcept.coding [
         fhir:index 0;
         fhir:Coding.code [ fhir:value "submitted" ]

     ] [
       fhir:category [
         fhir:coding ( [
           fhir:code [ fhir:v "eligpercent" ]
         ] )
       ] ;
       fhir:quantity [
         fhir:value [ fhir:v "80.00"^^xsd:decimal ]

       ]
     ];
     fhir:ClaimResponse.total.amount [
       fhir:Money.value [ fhir:value "1340.57"^^xsd:decimal ];
       fhir:Money.currency [ fhir:value "USD" ]
     ]
  ], [
     fhir:index 1;
     fhir:ClaimResponse.total.category [
       fhir:CodeableConcept.coding [
         fhir:index 0;
         fhir:Coding.code [ fhir:value "benefit" ]

     ] [
       fhir:category [
         fhir:coding ( [
           fhir:code [ fhir:v "benefit" ]
         ] )
       ] ;
       fhir:amount [
         fhir:value [ fhir:v "270.00"^^xsd:decimal ] ;
         fhir:currency [ fhir:v "USD" ]

       ]
     ];
     fhir:ClaimResponse.total.amount [
       fhir:Money.value [ fhir:value "1054.47"^^xsd:decimal ];
       fhir:Money.currency [ fhir:value "USD" ]

     ] )
  ] ) ; #   Pays for a claim package code (1200) with two actual codes (1101, 2141) with adjudication details  
  fhir:total ( [
     fhir:category [
       fhir:coding ( [
         fhir:code [ fhir:v "submitted" ]
       ] )
     ] ;
     fhir:amount [
       fhir:value [ fhir:v "1340.57"^^xsd:decimal ] ;
       fhir:currency [ fhir:v "USD" ]

     ]
  ];
  fhir:ClaimResponse.payment [
     fhir:ClaimResponse.payment.type [
       fhir:CodeableConcept.coding [
         fhir:index 0;
         fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/ex-paymenttype" ];
         fhir:Coding.code [ fhir:value "complete" ]
       ]
     ];
     fhir:ClaimResponse.payment.date [ fhir:value "2014-08-31"^^xsd:date ];
     fhir:ClaimResponse.payment.amount [
       fhir:Money.value [ fhir:value "100.47"^^xsd:decimal ];
       fhir:Money.currency [ fhir:value "USD" ]
     ];
     fhir:ClaimResponse.payment.identifier [
       fhir:Identifier.system [ fhir:value "http://www.BenefitsInc.com/fhir/paymentidentifier" ];
       fhir:Identifier.value [ fhir:value "201408-2-15507" ]

  ] [
     fhir:category [
       fhir:coding ( [
         fhir:code [ fhir:v "benefit" ]
       ] )
     ] ;
     fhir:amount [
       fhir:value [ fhir:v "1054.47"^^xsd:decimal ] ;
       fhir:currency [ fhir:v "USD" ]

     ]
  ];
  fhir:ClaimResponse.processNote [
     fhir:index 0;
     fhir:ClaimResponse.processNote.number [ fhir:value "101"^^xsd:positiveInteger ];
     fhir:ClaimResponse.processNote.type [ fhir:value "print" ];
     fhir:ClaimResponse.processNote.text [ fhir:value "Package codes are not permitted. Codes replaced by Insurer." ];
     fhir:ClaimResponse.processNote.language [
       fhir:CodeableConcept.coding [
         fhir:index 0;
         fhir:Coding.system [ fhir:value "urn:ietf:bcp:47" ];
         fhir:Coding.code [ fhir:value "en-CA" ]
       ]

  ] ) ; # 
  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:date [ fhir:v "2014-08-31"^^xsd:date ] ;
     fhir:amount [
       fhir:value [ fhir:v "100.47"^^xsd:decimal ] ;
       fhir:currency [ fhir:v "USD" ]
     ] ;
     fhir:identifier [
       fhir:system [ fhir:v "http://www.BenefitsInc.com/fhir/paymentidentifier"^^xsd:anyURI ] ;
       fhir:value [ fhir:v "201408-2-15507" ]

     ]
  ] .

<http://hl7.org/fhir/Patient/1> a fhir:Patient .

<http://hl7.org/fhir/Organization/1> a fhir:Organization .

# - ontology header ------------------------------------------------------------

<http://hl7.org/fhir/ClaimResponse/R3503.ttl> a owl:Ontology;
  owl:imports fhir:fhir.ttl;
  owl:versionIRI <http://build.fhir.org/ClaimResponse/R3503.ttl> .

  ] ; #   Payment details  
  fhir:processNote ( [
     fhir:number [ fhir:v "101"^^xsd:positiveInteger ] ;
     fhir:type [
       fhir:coding ( [
         fhir:system [ fhir:v "http://hl7.org/fhir/note-type"^^xsd:anyURI ] ;
         fhir:code [ fhir:v "print" ]
       ] )
     ] ;
     fhir:text [ fhir:v "Package codes are not permitted. Codes replaced by Insurer." ] ;
     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.