General Person Primary Coverage Example (id = "R3500")

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



  

  
    
    
  

  
    
    
  

  

  
    
      
      
    
  

  
    
      
      
    
  

  
  
  
    
  

  

  
    
      
      
    
  

  
    
  

  
    
  

  
  
  

  
    
      
      
    
  

  

  

     

    
      
        
          
        
      
      
        
        
      
    

    
      
        
          
        
      
      
        
        
        
    

    
      
        
          
        
      
      
    
    
      
        
          
        
      
      
        
          
          
          
          
        
      
      
        
        
        
    

  

  
    
      
        
      
    
    
      
       
     
  
  
  
    
      
        
      
    
    
      
       
     
  

  
  
    
      
        
        
      
      

    

    
      
      
      

    
      
      
      
  

<ClaimResponse xmlns="http://hl7.org/fhir">
  <id value="R3500"/> 
  <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://www.BenefitsInc.com/fhir/remittance"/> 
    <value value="R3500"/> 
  </identifier> 
  <status value="active"/> 
  <type> 
    <coding> 
      <system value="http://terminology.hl7.org/CodeSystem/claim-type"/> 
      <code value="oral"/> 
    </coding> 
  </type> 
  <subType> 
    <coding> 
      <system value="http://terminology.hl7.org/CodeSystem/ex-claimsubtype"/> 
      <code value="emergency"/> 
    </coding> 
  </subType> 
  <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="Organization/1"/>   </requestor>   <request>     <reference value="http://www.BenefitsInc.com/fhir/oralhealthclaim/15476332402"/>   </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="135.57"/>         <currency value="USD"/>       </amount>     </adjudication>     <adjudication>       <category>         <coding>           <code value="copay"/>         </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>       <reason>         <coding>           <system value="http://terminology.hl7.org/CodeSystem/adjudication-reason"/>           <code value="ar002"/>           <display value="Plan Limit Reached"/>             <!--   should have paid 100.47   -->        </coding>       </reason>       <amount>         <value value="90.47"/>         <currency value="USD"/>       </amount>       </adjudication>   </item>   <total>     <category>       <coding>         <code value="submitted"/>       </coding>     </category>     <amount>       <value value="135.57"/>       <currency value="USD"/>      </amount>    </total> 
  
  <total>     <category>       <coding>         <code value="benefit"/>       </coding>     </category>     <amount>       <value value="90.47"/>       <currency value="USD"/>      </amount>    </total>     <!--   Payment details   -->  <payment>     <type>       <coding>         <system value="http://terminology.hl7.org/CodeSystem/ex-paymenttype"/>         <code value="complete"/>       </coding>     </type>       <date value="2014-08-31"/>     <amount>       <value value="100.47"/>       <currency value="USD"/>     </amount>       <identifier>       <system value="http://www.BenefitsInc.com/fhir/paymentidentifier"/>       <value value="201408-2-1569478"/>     </identifier>     </payment> 


</

ClaimResponse

>