ClaimResponse
ID: 204687
Payload:
{
"resourceType": "ClaimResponse",
"meta": {
"versionId": "1",
"lastUpdated": "2019-10-03T07:55:35.966+00:00"
},
"text": {
"status": "generated",
"div": "<div xmlns=\"http://www.w3.org/1999/xhtml\">Ahuman-readablerenderingofthe
ClaimResponse</div>"
},
"identifier": [
{
"system": "http://www.BenefitsInc.com/fhir/remittance",
"value": "R3500"
}
],
"created": "2014-08-16",
"outcome": "complete",
"disposition": "Claimsettledaspercontract.",
"item": [
{
"adjudication": [
{
"amount": {
"value": 135.57
}
},
{
"amount": {
"value": 10
}
},
{
"value": 80
},
{
"amount": {
"value": 90.47
}
}
]
}
]
ID: 2588201
Payload:
{
"resourceType": "ClaimResponse",
"meta": {
"versionId": "1",
"lastUpdated": "2019-09-18T09:00:55.689+00:00"
},
"text": {
"status": "generated",
"div": "<div xmlns=\"http://www.w3.org/1999/xhtml\">A human-readable rendering of the
ClaimResponse</div>"
},
"identifier": [
{
"system": "http://www.BenefitsInc.com/fhir/remittance",
"value": "R3500"
}
],
"created": "2014-08-16",
"outcome": "complete",
"disposition": "Claim settled as per contract.",
"item": [
{
"adjudication": [
{
"amount": {
"value": 135.57
}
},
{
"amount": {
"value": 10
}
},
{
"value": 80
},
{
"amount": {
"value": 90.47
}
}
]
}
]
}
ID: 5e2a97c6-cbd2-4ac3-b048-3d1f40f3dfc9
Payload:
{
"resourceType": "ClaimResponse",
"id": "R3500",
"text": {
"status": "generated",
"div": "<div xmlns=\"http://www.w3.org/1999/xhtml\">A human-readable rendering of the
ClaimResponse</div>"
},
"identifier": [
{
"system": "http://www.BenefitsInc.com/fhir/remittance",
"value": "R3500"
}
],
"status": "active",
"patient": {
"reference": "Patient/0ca5428a-b129-4042-90d4-ccc588f75789"
},
"created": "2014-08-16",
"insurer": {
"identifier": {
"system": "http://www.jurisdiction.org/insurers",
"value": "555123"
}
},
"requestProvider": {
"reference": "Practitioner/ffc200e1-5721-4c70-8496-62ca8e9ce754"
},
"requestOrganization": {
"reference": "Organization/b0e04623-b02c-3f8b-92ea-943fc4db60da"
},
"request": {
"reference": "http://www.BenefitsInc.com/fhir/oralhealthclaim/15476332402"
},
"outcome": {
"coding": [
{
"system": "http://hl7.org/fhir/remittance-outcome",
"code": "complete"
}
]
},
"disposition": "Claim settled as per contract.",
"payeeType": {
"coding": [
{
"system": "http://hl7.org/fhir/payeetype",
"code": "provider"
}
]
},
"item": [
{
"sequenceLinkId": 1,
"adjudication": [
{
"category": {
"coding": [
{
"code": "eligible"
}
]
},
"amount": {
"value": 135.57,
"system": "urn:iso:std:iso:4217",
"code": "USD"
}
},
{
"category": {
"coding": [
{
"code": "copay"
}
]
},
"amount": {
"value": 10,
"system": "urn:iso:std:iso:4217",
"code": "USD"
}
},
{
"category": {
"coding": [
{
"code": "eligpercent"
}
]
},
"value": 80
},
{
"category": {
"coding": [
{
"code": "benefit"
}
]
},
"amount": {
"value": 100.47,
"system": "urn:iso:std:iso:4217",
"code": "USD"
}
}
]
}
],
"totalCost": {
"value": 135.57,
"system": "urn:iso:std:iso:4217",
"code": "USD"
},
"totalBenefit": {
"value": 100.47,
"system": "urn:iso:std:iso:4217",
"code": "USD"
},
"payment": {
"type": {
"coding": [
{
"system": "http://hl7.org/fhir/ex-paymenttype",
"code": "complete"
}
]
},
"date": "2014-08-31",
"amount": {
"value": 100.47,
"system": "urn:iso:std:iso:4217",
"code": "USD"
},
"identifier": {
"system": "http://www.BenefitsInc.com/fhir/paymentidentifier",
"value": "201408-2-1569478"
}
}
}