Primary insurance response to a 3Tier Vision Claim (id = "R3502")

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



  

  
    
    
  

  
    
    
  

  

  
    
      
      
    
  
  
  

  
    
  

  

  
    
  

  
    
  

  
     
      
      
    
  

  

  

  
    
      
      
    
  

  

  

     

    
      
        
          
        
      
      
        
        
      
    

    
      
        
          
        
      
      
        
        
        
    

    
      
        
          
        
      
      
    

    
      
        
          
        
      
      
        
        
        
    

    
       
      

      
        
          
            
          
        
        
          
          
        
      

      
        
          
            
          
        
        
          
          
          
      

      
        
          
            
          
        
        
      

      
        
          
            
          
        
        
          
          
          
      
    
    
       
      

      
        
          
            
          
        
        
          
          
        
      

      
        
          
            
          
        
        
      

      
        
          
            
          
        
        
          
          
          
      

      
         
        

        
          
            
              
            
          
          
            
            
          
        

        
          
            
              
            
          
          
        

        
          
            
              
            
          
          
            
            
            
        

      
      
         

        
          
            
              
            
          
          
            
            
          
        

        
          
            
              
            
          
          
        

        
          
            
              
            
          
          
            
            
            
        

      
      
         
        

        
          
            
              
            
          
          
            
            
          
        

        
          
            
              
            
          
          
        

        
          
            
              
            
          
          
            
            
            
        

      
    
    
       
      

      
        
          
            
          
        
        
          
          
        
      

      
        
          
            
          
        
        
      

      
        
          
            
          
        
        
          
          
          
      
    

  

  
    
      
        
      
    
    
      
       
     
  

  
    
      
        
      
    
    
      
       
     
  

  
  
    
      
        
        
      
      

    
      
      
    

    
      
        
        
        
      
    

    

    
      
      
      

    
      
      
      
  

  
    
    
    
    
      
        
        
      
    
    

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


</

ClaimResponse

>