This page is part of the FHIR Specification (v0.0.82: DSTU 1). 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 R3 R2 Content Examples Detailed Descriptions Mappings Profiles 7.2.5 Resource ClaimResponse - Examples Example Index: General Person Primary Coverage Example XML JSON 7.2.5.1 General-Primary XML General Person Primary Coverage Example (id = "R3500") Raw XML </ClaimResponse> JSON General Person Primary Coverage Example Raw JSON ( Canonical ) { "resourceType": "ClaimResponse", "id": "R3500", "text": { "status": "generated", "div": "<div>!-- Snipped for Brevity --></div>" }, "identifier": [ { "system": "http://www.BenefitsInc.com/fhir/remittance", "value": "R3500" } ], "request": { "reference": "http://www.BenefitsInc.com/fhir/oralhealthclaim/15476332402" }, "created": "2014-08-16", "organization": { "reference": "Organization/2" }, "requestOrganization": { "reference": "Organization/1" }, "outcome": "complete", "disposition": "Claim settled as per contract.", "payeeType": { "system": "http://hl7.org/fhir/payeetype", "code": "provider" }, "item": [ { "sequenceLinkId": 1, "adjudication": [ { "code": { "code": "eligible" }, "amount": { "value": 135.57, "system": "urn:std:iso:4217", "code": "USD" } }, { "code": { "code": "copay" }, "amount": { "value": 10.00, "system": "urn:std:iso:4217", "code": "USD" } }, { "code": { "code": "eligpercent" }, "value": 80.00 }, { "code": { "code": "benefit" }, "amount": { "value": 100.47, "system": "urn:std:iso:4217", "code": "USD" } } ] } ], "totalCost": { "value": 135.57, "system": "urn:std:iso:4217", "code": "USD" }, "totalBenefit": { "value": 100.47, "system": "urn:std:iso:4217", "code": "USD" }, "paymentDate": "2014-08-31", "paymentAmount": { "value": 100.47, "system": "urn:std:iso:4217", "code": "USD" }, "paymentRef": { "system": "http://www.BenefitsInc.com/fhir/paymentRef", "value": "201408-2-1569478" } } 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. © HL7.org 2011+. FHIR DSTU (v0.4.0-4902) generated on Fri, Mar 27, 2015 00:18+1100. Links: What's a DSTU? | Version History | Specification Map | Compare to DSTU1 | | Propose a change