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ClaimResponse "R3500" Version "1"

Created by SYSTEM () at 11/28/2017 8:28:09 AM(UTC)

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A human-readable rendering of the ClaimResponse

<?xml version="1.0" encoding="UTF-8"?>
<ClaimResponse xmlns="http://hl7.org/fhir">
  <id value="R3500"/>
  <meta>
    <versionId value="1"/>
    <lastUpdated value="2017-11-28T08:28:09Z"/>
  </meta>
  <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"/>
  <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>
  <requestProvider>
    <reference value="Practitioner/1"/>
  </requestProvider>
  <requestOrganization>
    <reference value="Organization/1"/>
  </requestOrganization>
  <request>
    <reference value="http://www.BenefitsInc.com/fhir/oralhealthclaim/15476332402"/>
  </request>
  <outcome>
    <coding>
      <system value="http://hl7.org/fhir/remittance-outcome"/>
      <code value="complete"/>
    </coding>
  </outcome>
  <disposition value="Claim settled as per contract."/>
  <payeeType>
    <coding>
      <system value="http://hl7.org/fhir/payeetype"/>
      <code value="provider"/>
    </coding>
  </payeeType>
  <item>
    <sequenceLinkId value="1"/>
    <adjudication>
      <category>
        <coding>
          <code value="eligible"/>
        </coding>
      </category>
      <amount>
        <value value="135.57"/>
        <system value="urn:iso:std:iso:4217"/>
        <code value="USD"/>
      </amount>
    </adjudication>
    <adjudication>
      <category>
        <coding>
          <code value="copay"/>
        </coding>
      </category>
      <amount>
        <value value="10.00"/>
        <system value="urn:iso:std:iso:4217"/>
        <code value="USD"/>
      </amount>
    </adjudication>
    <adjudication>
      <category>
        <coding>
          <code value="eligpercent"/>
        </coding>
      </category>
      <value value="80.00"/>
    </adjudication>
    <adjudication>
      <category>
        <coding>
          <code value="benefit"/>
        </coding>
      </category>
      <amount>
        <value value="100.47"/>
        <system value="urn:iso:std:iso:4217"/>
        <code value="USD"/>
      </amount>
    </adjudication>
  </item>
  <totalCost>
    <value value="135.57"/>
    <system value="urn:iso:std:iso:4217"/>
    <code value="USD"/>
  </totalCost>
  <totalBenefit>
    <value value="100.47"/>
    <system value="urn:iso:std:iso:4217"/>
    <code value="USD"/>
  </totalBenefit>
  <payment>
    <type>
      <coding>
        <system value="http://hl7.org/fhir/ex-paymenttype"/>
        <code value="complete"/>
      </coding>
    </type>
    <date value="2014-08-31"/>
    <amount>
      <value value="100.47"/>
      <system value="urn:iso:std:iso:4217"/>
      <code value="USD"/>
    </amount>
    <identifier>
      <system value="http://www.BenefitsInc.com/fhir/paymentidentifier"/>
      <value value="201408-2-1569478"/>
    </identifier>
  </payment>
</ClaimResponse>