FHIR © HL7.org  |  Server Home  |  Health Intersections FHIR Server v1.0.217  |  FHIR Version 3.0.1  | User: ANONYMOUS (Unknown)  

History Record

XML or JSON representation

Links: First Previous Next Last  (10 found). Search: http://test.fhir.org/r3/ClaimResponse/_history?&_prior=2018-02-19T17:58:00Z&_format=text/xhtml&history-id=8a60f768-8e4c-49a4-89d6-34b147a07e 

SQL (for debugging): Insert into SearchEntries Select 25912, Ids.ResourceKey, Versions.ResourceVersionKey, RIGHT ('0000000000000'+CAST(Versions.ResourceVersionKey AS VARCHAR(14)),14) as sort, null, null from Versions, Ids, Sessions where Ids.ResourceTypeKey = 18 and Versions.ResourceKey = Ids.ResourceKey and Versions.SessionKey = Sessions.SessionKey order by ResourceVersionKey DESC

ClaimResponse 5 deleted

Deleted by ANONYMOUS (Unknown) at 1/4/2018 4:55:32 PM(UTC) (Audit)

ClaimResponse 5 deleted

Deleted by ANONYMOUS (Unknown) at 1/4/2018 4:55:31 PM(UTC) (Audit)

ClaimResponse "5" Version "2"

Updated by ANONYMOUS (Unknown) at 1/4/2018 4:55:12 PM(UTC) (Audit)

Tags: (no tags)  +

This Resource , XML or JSON representation, or the full version history.. provenance for this resource
Updated: by

7UyvNg1TGllYG8WGgWS62g==

<?xml version="1.0" encoding="UTF-8"?>
<ClaimResponse xmlns="http://hl7.org/fhir">
  <id value="5"/>
  <meta>
    <versionId value="2"/>
    <lastUpdated value="2018-01-04T16:55:12Z"/>
    <tag>
      <system value="http://projectcrucible.org"/>
      <code value="testdata"/>
    </tag>
  </meta>
  <language value="it-CH"/>
  <text>
    <status value="generated"/>
    <div xmlns="http://www.w3.org/1999/xhtml">7UyvNg1TGllYG8WGgWS62g==</div>
  </text>
  <identifier>
    <use value="secondary"/>
    <type>
      <coding>
        <system value="http://hl7.org/fhir/v2/0203"/>
        <code value="EN"/>
        <display value="Employer number"/>
        <userSelected value="false"/>
      </coding>
      <text value="zR5rTp0BXgVlYHQJL5HZNg=="/>
    </type>
    <system value="http://projectcrucible.org/D+fTTd1BQZ28CZ4grLbtfA=="/>
    <value value="dl7VlHE7+iFYg2qZFQq7Pg=="/>
    <period>
      <start value="2018-01-04T11:55:11.739Z"/>
      <end value="2018-01-04T11:55:11.739Z"/>
    </period>
    <assigner>
      <identifier>
        <use value="temp"/>
        <system value="http://projectcrucible.org/UxKez+w49yMvx2ayV7gg8Q=="/>
        <value value="UIsftEOf0m7gW89nZ21CYQ=="/>
      </identifier>
      <display value="Organization mNkB+BdJT04D9yc3DCJjvg=="/>
    </assigner>
  </identifier>
  <status value="entered-in-error"/>
  <patient>
    <identifier>
      <use value="usual"/>
      <type>
        <text value="e129L+zJlKjBYrAEJU1Z9w=="/>
      </type>
      <system value="http://projectcrucible.org/3Q/dX0HFJ5tPwGW/LjxWRA=="/>
      <value value="B4zjrqfAgJqtikbdM6XH3w=="/>
      <period>
        <start value="2018-01-04T11:55:11.740Z"/>
        <end value="2018-01-04T11:55:11.740Z"/>
      </period>
      <assigner>
        <display value="Organization dqa43+fCszU2LZragvX0sw=="/>
      </assigner>
    </identifier>
    <display value="Patient i3ZjTjN4n26cWBgnXoXzgg=="/>
  </patient>
  <created value="2018-01-04T11:55:11.740Z"/>
  <insurer>
    <identifier>
      <use value="temp"/>
      <type>
        <text value="DPKQlF+6LdPvb2utujHmJg=="/>
      </type>
      <system value="http://projectcrucible.org/O19F9qGAJJZJhJaLzZCILQ=="/>
      <value value="/7DDJtlb8eH5RSkxT5MrxA=="/>
      <period>
        <start value="2018-01-04T11:55:11.741Z"/>
        <end value="2018-01-04T11:55:11.741Z"/>
      </period>
      <assigner>
        <display value="Organization 4kHRsCv96rDFcFnrJ8BbAA=="/>
      </assigner>
    </identifier>
    <display value="Organization 4MfFnV73H3C9ba/36vX5Og=="/>
  </insurer>
  <requestProvider>
    <identifier>
      <use value="official"/>
      <type>
        <text value="z1CQAZok3qlwPoVWnSGTlg=="/>
      </type>
      <system value="http://projectcrucible.org/4xu3JU1RH/MYz1dNf9I6kw=="/>
      <value value="ITEG9oe0mrDfG3g2ot/bLA=="/>
      <period>
        <start value="2018-01-04T11:55:11.741Z"/>
        <end value="2018-01-04T11:55:11.741Z"/>
      </period>
      <assigner>
        <display value="Organization lBZdfdXohcZVO1uIymMdow=="/>
      </assigner>
    </identifier>
    <display value="Practitioner +XWcSpZLZvBA9lUQcOYfMg=="/>
  </requestProvider>
  <requestOrganization>
    <identifier>
      <use value="official"/>
      <type>
        <text value="+7BJ6utoNP9FbJEis/IL2Q=="/>
      </type>
      <system value="http://projectcrucible.org/ifcm4RiHIQnrIRYf59zsWw=="/>
      <value value="i1lWmQkJPLTUjEH5TguPTA=="/>
      <period>
        <start value="2018-01-04T11:55:11.742Z"/>
        <end value="2018-01-04T11:55:11.742Z"/>
      </period>
      <assigner>
        <display value="Organization 6UMeDhlCfQwyV1WWeio+oA=="/>
      </assigner>
    </identifier>
    <display value="Organization sSqELQu+H4pw2ZZ2k3xh9w=="/>
  </requestOrganization>
  <request>
    <identifier>
      <use value="official"/>
      <type>
        <text value="Ieu2ICTHNu5aj9N8TQeavw=="/>
      </type>
      <system value="http://projectcrucible.org/OAaskacpVRNLvXH09E69/A=="/>
      <value value="2otmvrcZEWXGaKRbg6F33w=="/>
      <period>
        <start value="2018-01-04T11:55:11.743Z"/>
        <end value="2018-01-04T11:55:11.743Z"/>
      </period>
      <assigner>
        <display value="Organization 9LPLDz1qTGjWCg3vRciogQ=="/>
      </assigner>
    </identifier>
    <display value="Claim pSsbxI9fUcF+ymq+onRl7g=="/>
  </request>
  <outcome>
    <coding>
      <system value="http://hl7.org/fhir/remittance-outcome"/>
      <code value="error"/>
      <display value="Error"/>
      <userSelected value="false"/>
    </coding>
    <text value="Pzu9cWO1j6I0R0s7oUu99A=="/>
  </outcome>
  <disposition value="YqtUFsQ8Ocs/u90zRnQV6A=="/>
  <payeeType>
    <coding>
      <system value="http://hl7.org/fhir/payeetype"/>
      <code value="other"/>
      <display value="Provider"/>
      <userSelected value="false"/>
    </coding>
    <text value="fCPi0x1Qn74o4XCNSBLcww=="/>
  </payeeType>
  <item>
    <sequenceLinkId value="100"/>
    <noteNumber value="92"/>
    <adjudication>
      <category>
        <coding>
          <system value="http://hl7.org/fhir/adjudication"/>
          <code value="benefit"/>
        </coding>
      </category>
      <reason>
        <text value="MijCL6TBnuWnWus0xKbusw=="/>
      </reason>
      <amount>
        <value value="0.44695771576962773"/>
        <system value="urn:iso:std:iso:4217"/>
        <code value="USD"/>
      </amount>
      <value value="0.1563006945284917"/>
    </adjudication>
    <detail>
      <sequenceLinkId value="7"/>
      <noteNumber value="16"/>
      <adjudication>
        <category>
          <coding>
            <system value="http://hl7.org/fhir/adjudication"/>
            <code value="benefit"/>
          </coding>
        </category>
        <value value="0.8238407221760489"/>
      </adjudication>
      <subDetail>
        <sequenceLinkId value="28"/>
        <noteNumber value="15"/>
      </subDetail>
    </detail>
  </item>
  <addItem>
    <sequenceLinkId value="32"/>
    <revenue>
      <coding>
        <system value="http://hl7.org/fhir/ex-revenue-center"/>
        <code value="0010"/>
        <display value="Vision Clinic"/>
        <userSelected value="false"/>
      </coding>
      <text value="TfCL3yL9DTap6SpXslRY4g=="/>
    </revenue>
    <category>
      <coding>
        <system value="http://hl7.org/fhir/benefit-subcategory"/>
        <code value="F3"/>
        <display value="Dental Coverage"/>
        <userSelected value="true"/>
      </coding>
      <text value="nwx6sYz16I3+CPYLkfTtrA=="/>
    </category>
    <service>
      <coding>
        <system value="http://hl7.org/fhir/ex-USCLS"/>
        <code value="1201"/>
        <display value="Exam, recall"/>
        <userSelected value="true"/>
      </coding>
      <text value="9+54oU5IrA6OAO39F7msQA=="/>
    </service>
    <modifier>
      <coding>
        <system value="http://hl7.org/fhir/modifiers"/>
        <code value="rooh"/>
        <display value="Rush or Outside of office hours"/>
        <userSelected value="true"/>
      </coding>
      <text value="Q5uyKjgMTYv08gg/+e3TZA=="/>
    </modifier>
    <fee>
      <value value="0.40999320114273696"/>
      <system value="urn:iso:std:iso:4217"/>
      <code value="USD"/>
    </fee>
    <noteNumber value="14"/>
    <adjudication>
      <category>
        <coding>
          <system value="http://hl7.org/fhir/adjudication"/>
          <code value="benefit"/>
        </coding>
      </category>
      <reason>
        <text value="MyW1IWV+jzz7fpqNEFh3Dw=="/>
      </reason>
      <amount>
        <value value="0.9694538225511334"/>
        <system value="urn:iso:std:iso:4217"/>
        <code value="USD"/>
      </amount>
      <value value="0.4746327188740608"/>
    </adjudication>
    <detail>
      <revenue>
        <text value="vblEdodEE4QaCVTrWlO6ZQ=="/>
      </revenue>
      <category>
        <text value="h4iYkVKya799st3tQC6/BQ=="/>
      </category>
      <service>
        <text value="8+G7tSf/0hS9XX7wqq73nw=="/>
      </service>
      <modifier>
        <text value="aeWqffo7B7rWLAk54l//HA=="/>
      </modifier>
      <fee>
        <value value="0.474265058201341"/>
        <system value="urn:iso:std:iso:4217"/>
        <code value="USD"/>
      </fee>
      <noteNumber value="67"/>
      <adjudication>
        <category>
          <coding>
            <system value="http://hl7.org/fhir/adjudication"/>
            <code value="benefit"/>
          </coding>
        </category>
        <value value="0.20655467379424075"/>
      </adjudication>
    </detail>
  </addItem>
  <error>
    <sequenceLinkId value="86"/>
    <detailSequenceLinkId value="70"/>
    <subdetailSequenceLinkId value="24"/>
    <code>
      <coding>
        <system value="http://hl7.org/fhir/adjudication-error"/>
        <code value="a002"/>
        <display value="Missing Creation Date"/>
        <userSelected value="false"/>
      </coding>
      <text value="WschOsNwKxC/XFyIZ2QC5w=="/>
    </code>
  </error>
  <totalCost>
    <value value="0.6833347514897912"/>
    <system value="urn:iso:std:iso:4217"/>
    <code value="USD"/>
  </totalCost>
  <unallocDeductable>
    <value value="0.6425792284945323"/>
    <system value="urn:iso:std:iso:4217"/>
    <code value="USD"/>
  </unallocDeductable>
  <totalBenefit>
    <value value="0.7955393284445864"/>
    <system value="urn:iso:std:iso:4217"/>
    <code value="USD"/>
  </totalBenefit>
  <payment>
    <type>
      <coding>
        <system value="http://hl7.org/fhir/ex-paymenttype"/>
        <code value="partial"/>
        <display value="Partial"/>
        <userSelected value="true"/>
      </coding>
      <text value="dlI4wxYfF0iA9Flo0UV7eA=="/>
    </type>
    <adjustment>
      <value value="0.5837725261480075"/>
      <system value="urn:iso:std:iso:4217"/>
      <code value="USD"/>
    </adjustment>
    <adjustmentReason>
      <coding>
        <system value="http://hl7.org/fhir/payment-adjustment-reason"/>
        <code value="a002"/>
        <display value="Prior Overpayment"/>
        <userSelected value="true"/>
      </coding>
      <text value="872581Eklyz0id9X4rh1Sw=="/>
    </adjustmentReason>
    <date value="2018-01-04"/>
    <amount>
      <value value="0.4639174663389952"/>
      <system value="urn:iso:std:iso:4217"/>
      <code value="USD"/>
    </amount>
    <identifier>
      <use value="official"/>
      <type>
        <text value="LgFKWVJ4XQtWI23ZEx1OBg=="/>
      </type>
      <system value="http://projectcrucible.org/6wSmBA9zoUZdsTp/hhfD4g=="/>
      <value value="678zUW/vGxlodAM4PX596Q=="/>
      <period>
        <start value="2018-01-04T11:55:11.758Z"/>
        <end value="2018-01-04T11:55:11.758Z"/>
      </period>
      <assigner>
        <display value="Organization yp/aYhNou4euTT6GGr73bQ=="/>
      </assigner>
    </identifier>
  </payment>
  <reserved>
    <system value="http://hl7.org/fhir/fundsreserve"/>
    <code value="none"/>
    <display value="None"/>
    <userSelected value="true"/>
  </reserved>
  <form>
    <coding>
      <system value="http://hl7.org/fhir/forms-codes"/>
      <code value="1"/>
      <display value="Form #1"/>
      <userSelected value="false"/>
    </coding>
    <text value="eyWjjUT0R5q7kckMP9PbPA=="/>
  </form>
  <processNote>
    <number value="52"/>
    <type>
      <coding>
        <system value="http://hl7.org/fhir/note-type"/>
        <code value="display"/>
        <display value="Display"/>
        <userSelected value="false"/>
      </coding>
      <text value="MqZA1d5mVyqErGZ7ZyiXIw=="/>
    </type>
    <text value="l8cYLp39XNorXUDi7GJKmA=="/>
    <language>
      <coding>
        <system value="urn:ietf:bcp:47"/>
        <code value="it-CH"/>
        <display value="Italiensk (Schweiz)"/>
        <userSelected value="false"/>
      </coding>
      <text value="RgWS034/vhCiopasLqh2mQ=="/>
    </language>
  </processNote>
  <communicationRequest>
    <identifier>
      <use value="secondary"/>
      <type>
        <text value="BDKqKrewFFA/WIkeP49sNQ=="/>
      </type>
      <system value="http://projectcrucible.org//oGlzwJfDQ9YNF4+v0SBEg=="/>
      <value value="uwBa37W4nUlcdcuLvC8ZEA=="/>
      <period>
        <start value="2018-01-04T11:55:11.773Z"/>
        <end value="2018-01-04T11:55:11.774Z"/>
      </period>
      <assigner>
        <display value="Organization 0/+Xc/1HBao6Ulkw4AWZKQ=="/>
      </assigner>
    </identifier>
    <display value="CommunicationRequest E65t8DdXLzM7JAC61RTENA=="/>
  </communicationRequest>
  <insurance>
    <sequence value="85"/>
    <focal value="false"/>
    <coverage>
      <identifier>
        <use value="temp"/>
        <system value="http://projectcrucible.org/Luf9lVPdI2/o9A3Mv642Dw=="/>
        <value value="gvIvFVWfPAEmPFBWssPn8g=="/>
      </identifier>
      <display value="Coverage XIM1HxY9ecyqn7NCk5EcHg=="/>
    </coverage>
    <businessArrangement value="4i0AptVTDuOa89RVBgJPvw=="/>
    <preAuthRef value="S4xiPV3DpqVGM8HLq5qDHw=="/>
    <claimResponse>
      <identifier>
        <use value="official"/>
        <system value="http://projectcrucible.org/I2m9+xDnwZb3jahlAVV0Yg=="/>
        <value value="PoM/uXT/sxNgJwyEKs6Rbg=="/>
      </identifier>
      <display value="ClaimResponse 3JjpPN1us9yL5V9z0MC4ug=="/>
    </claimResponse>
  </insurance>
</ClaimResponse>

ClaimResponse "5" Version "1"

Created by ANONYMOUS (Unknown) at 1/4/2018 4:55:10 PM(UTC) (Audit)

Tags: (no tags)  +

This Resource , XML or JSON representation, or the full version history.. provenance for this resource
Updated: by

YcDQF5GuH7wYr8KULfgbEQ==

<?xml version="1.0" encoding="UTF-8"?>
<ClaimResponse xmlns="http://hl7.org/fhir">
  <id value="5"/>
  <meta>
    <versionId value="1"/>
    <lastUpdated value="2018-01-04T16:55:10Z"/>
    <tag>
      <system value="http://projectcrucible.org"/>
      <code value="testdata"/>
    </tag>
  </meta>
  <language value="en-AU"/>
  <text>
    <status value="generated"/>
    <div xmlns="http://www.w3.org/1999/xhtml">YcDQF5GuH7wYr8KULfgbEQ==</div>
  </text>
  <identifier>
    <use value="secondary"/>
    <type>
      <coding>
        <system value="http://hl7.org/fhir/v2/0203"/>
        <code value="ACSN"/>
        <display value="Accession ID"/>
        <userSelected value="true"/>
      </coding>
      <text value="UieGvw8/+H1NenY49sZaig=="/>
    </type>
    <system value="http://projectcrucible.org/Fqyl8lNDw6qlfM17bWWo/g=="/>
    <value value="g3LnkK6syLe1pTIT5SlHug=="/>
    <period>
      <start value="2018-01-04T11:55:10.167Z"/>
      <end value="2018-01-04T11:55:10.167Z"/>
    </period>
    <assigner>
      <identifier>
        <use value="usual"/>
        <system value="http://projectcrucible.org/k4API4DYIIvWKRGOn03bZQ=="/>
        <value value="ZJFtZ1UBV0jmNr+B1LwStQ=="/>
      </identifier>
      <display value="Organization qupUhNVaC7uUex0hev3Wbg=="/>
    </assigner>
  </identifier>
  <status value="cancelled"/>
  <patient>
    <identifier>
      <use value="temp"/>
      <type>
        <text value="q00UWl+ijhgPju/NBTzPdg=="/>
      </type>
      <system value="http://projectcrucible.org/40lKHbJGjxcr/u6GZicojA=="/>
      <value value="WW4EGKHC46sRSXdUMOi9kQ=="/>
      <period>
        <start value="2018-01-04T11:55:10.168Z"/>
        <end value="2018-01-04T11:55:10.168Z"/>
      </period>
      <assigner>
        <display value="Organization Atl8n57tVawXQGYR9ktlKg=="/>
      </assigner>
    </identifier>
    <display value="Patient NSmwbYxz9PHXlT3Wnpv+uQ=="/>
  </patient>
  <created value="2018-01-04T11:55:10.168Z"/>
  <insurer>
    <identifier>
      <use value="usual"/>
      <type>
        <text value="8X36LYhhui+3C3C5+icX8g=="/>
      </type>
      <system value="http://projectcrucible.org/VvzBWaEIFVHBeIv+9x8djg=="/>
      <value value="5QJbvHW7po+KQ+5z/84pyw=="/>
      <period>
        <start value="2018-01-04T11:55:10.169Z"/>
        <end value="2018-01-04T11:55:10.169Z"/>
      </period>
      <assigner>
        <display value="Organization FWREdooIq+DP9SJLM/1E0Q=="/>
      </assigner>
    </identifier>
    <display value="Organization iQDCXYw3GM+UWLa7tXpGFQ=="/>
  </insurer>
  <requestProvider>
    <identifier>
      <use value="usual"/>
      <type>
        <text value="2zqWF/5KEC2AqPFE/noUGA=="/>
      </type>
      <system value="http://projectcrucible.org/IcBAtxlFgkJDLzfstNcYvw=="/>
      <value value="y3QbyLqlhBmfS21XWusrzg=="/>
      <period>
        <start value="2018-01-04T11:55:10.169Z"/>
        <end value="2018-01-04T11:55:10.169Z"/>
      </period>
      <assigner>
        <display value="Organization RQgIb3CElowrDAywdbltXA=="/>
      </assigner>
    </identifier>
    <display value="Practitioner 17hx36uLN9ZBNWqAUPXjGQ=="/>
  </requestProvider>
  <requestOrganization>
    <identifier>
      <use value="official"/>
      <type>
        <text value="zzRc/xgNaNrtov2DGsfbXQ=="/>
      </type>
      <system value="http://projectcrucible.org/6MH0//KoWIKLD+4tEGJAEQ=="/>
      <value value="13QMFEsK5327q3bDCRQnNw=="/>
      <period>
        <start value="2018-01-04T11:55:10.170Z"/>
        <end value="2018-01-04T11:55:10.170Z"/>
      </period>
      <assigner>
        <display value="Organization w9i4gZ0AwN1ikQ/qrsRHJQ=="/>
      </assigner>
    </identifier>
    <display value="Organization YlcNa8Vo3Q1nw5UXM5zRsw=="/>
  </requestOrganization>
  <request>
    <identifier>
      <use value="usual"/>
      <type>
        <text value="ChXdWBLwIL9l/ZpDt0oB9g=="/>
      </type>
      <system value="http://projectcrucible.org/oc+gjgZeqJ5EDOCn52T0Bw=="/>
      <value value="5seRlCZxi16aFnq3QB3nPg=="/>
      <period>
        <start value="2018-01-04T11:55:10.170Z"/>
        <end value="2018-01-04T11:55:10.170Z"/>
      </period>
      <assigner>
        <display value="Organization bcNj98zDGUWVueYxopW2Hw=="/>
      </assigner>
    </identifier>
    <display value="Claim A4l/GCtuPvL2Vj3xr/cUWg=="/>
  </request>
  <outcome>
    <coding>
      <system value="http://hl7.org/fhir/remittance-outcome"/>
      <code value="error"/>
      <display value="Error"/>
      <userSelected value="false"/>
    </coding>
    <text value="BBej0urcPxs8Pe1WvmYkHg=="/>
  </outcome>
  <disposition value="VHPXWjrx6rsGhxLVR8dJaw=="/>
  <payeeType>
    <coding>
      <system value="http://hl7.org/fhir/payeetype"/>
      <code value="provider"/>
      <display value="Provider"/>
      <userSelected value="false"/>
    </coding>
    <text value="Uy9zW3Mbs6cH1laqpxviLg=="/>
  </payeeType>
  <item>
    <sequenceLinkId value="59"/>
    <noteNumber value="75"/>
    <adjudication>
      <category>
        <coding>
          <system value="http://hl7.org/fhir/adjudication"/>
          <code value="benefit"/>
        </coding>
      </category>
      <reason>
        <text value="ZmFQgne8RrfRgzqmPSoOkg=="/>
      </reason>
      <amount>
        <value value="0.7249115737656858"/>
        <system value="urn:iso:std:iso:4217"/>
        <code value="USD"/>
      </amount>
      <value value="0.7031808478066526"/>
    </adjudication>
    <detail>
      <sequenceLinkId value="53"/>
      <noteNumber value="13"/>
      <adjudication>
        <category>
          <coding>
            <system value="http://hl7.org/fhir/adjudication"/>
            <code value="benefit"/>
          </coding>
        </category>
        <value value="0.7901460125719579"/>
      </adjudication>
      <subDetail>
        <sequenceLinkId value="68"/>
        <noteNumber value="42"/>
      </subDetail>
    </detail>
  </item>
  <addItem>
    <sequenceLinkId value="27"/>
    <revenue>
      <coding>
        <system value="http://hl7.org/fhir/ex-revenue-center"/>
        <code value="0440"/>
        <display value="Speech-Language Pathology"/>
        <userSelected value="true"/>
      </coding>
      <text value="H220Wlg2f/tVnPxZnyy5nw=="/>
    </revenue>
    <category>
      <coding>
        <system value="http://hl7.org/fhir/benefit-subcategory"/>
        <code value="25"/>
        <display value="Restorative"/>
        <userSelected value="false"/>
      </coding>
      <text value="ihvc+nLgUIBMTkBPmERq+w=="/>
    </category>
    <service>
      <coding>
        <system value="http://hl7.org/fhir/ex-USCLS"/>
        <code value="1101"/>
        <display value="Exam, comp, primary"/>
        <userSelected value="false"/>
      </coding>
      <text value="m5zDcApRzcXQSvShJZWd1A=="/>
    </service>
    <modifier>
      <coding>
        <system value="http://hl7.org/fhir/modifiers"/>
        <code value="e"/>
        <display value="Implant or associated with an implant"/>
        <userSelected value="false"/>
      </coding>
      <text value="hFEdn75v4PY8OCVX5mW6xA=="/>
    </modifier>
    <fee>
      <value value="0.8706208044801673"/>
      <system value="urn:iso:std:iso:4217"/>
      <code value="USD"/>
    </fee>
    <noteNumber value="72"/>
    <adjudication>
      <category>
        <coding>
          <system value="http://hl7.org/fhir/adjudication"/>
          <code value="benefit"/>
        </coding>
      </category>
      <reason>
        <text value="2w6PsxuDvSo1aKR+t3ISyA=="/>
      </reason>
      <amount>
        <value value="0.6528202702129843"/>
        <system value="urn:iso:std:iso:4217"/>
        <code value="USD"/>
      </amount>
      <value value="0.522424735146638"/>
    </adjudication>
    <detail>
      <revenue>
        <text value="lSAcj38wxIuGc+u2Q5Ln+A=="/>
      </revenue>
      <category>
        <text value="6EEhJ92WrTkzuCS+Z6uSGg=="/>
      </category>
      <service>
        <text value="HSQCUjDDCKBqr8IyzzpIVg=="/>
      </service>
      <modifier>
        <text value="FV3CDDSogI9ZVOGzWK+ApA=="/>
      </modifier>
      <fee>
        <value value="0.8863171882651565"/>
        <system value="urn:iso:std:iso:4217"/>
        <code value="USD"/>
      </fee>
      <noteNumber value="49"/>
      <adjudication>
        <category>
          <coding>
            <system value="http://hl7.org/fhir/adjudication"/>
            <code value="benefit"/>
          </coding>
        </category>
        <value value="0.9603285595517955"/>
      </adjudication>
    </detail>
  </addItem>
  <error>
    <sequenceLinkId value="63"/>
    <detailSequenceLinkId value="20"/>
    <subdetailSequenceLinkId value="83"/>
    <code>
      <coding>
        <system value="http://hl7.org/fhir/adjudication-error"/>
        <code value="a001"/>
        <display value="Missing Identifier"/>
        <userSelected value="true"/>
      </coding>
      <text value="JCrGY3I7G7jTYfCv5ntHdg=="/>
    </code>
  </error>
  <totalCost>
    <value value="0.23936601291471704"/>
    <system value="urn:iso:std:iso:4217"/>
    <code value="USD"/>
  </totalCost>
  <unallocDeductable>
    <value value="0.7071400387654582"/>
    <system value="urn:iso:std:iso:4217"/>
    <code value="USD"/>
  </unallocDeductable>
  <totalBenefit>
    <value value="0.5459976923931297"/>
    <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"/>
        <display value="Complete"/>
        <userSelected value="true"/>
      </coding>
      <text value="CbnYGwHt3RyCvwaNmDm2uQ=="/>
    </type>
    <adjustment>
      <value value="0.516063118395819"/>
      <system value="urn:iso:std:iso:4217"/>
      <code value="USD"/>
    </adjustment>
    <adjustmentReason>
      <coding>
        <system value="http://hl7.org/fhir/payment-adjustment-reason"/>
        <code value="a001"/>
        <display value="Prior Payment Reversal"/>
        <userSelected value="true"/>
      </coding>
      <text value="3p6cZ+W41dsT+RtUicjpVA=="/>
    </adjustmentReason>
    <date value="2018-01-04"/>
    <amount>
      <value value="0.6536509132725069"/>
      <system value="urn:iso:std:iso:4217"/>
      <code value="USD"/>
    </amount>
    <identifier>
      <use value="secondary"/>
      <type>
        <text value="tw2IrkjmyBV/llBEDniIZQ=="/>
      </type>
      <system value="http://projectcrucible.org/jTD7oufbu2AnLx8xZcgGCg=="/>
      <value value="NBgVkVJlYYg6k1xNkvs0RQ=="/>
      <period>
        <start value="2018-01-04T11:55:10.182Z"/>
        <end value="2018-01-04T11:55:10.182Z"/>
      </period>
      <assigner>
        <display value="Organization /wdUDpryFC7miDFsL563yw=="/>
      </assigner>
    </identifier>
  </payment>
  <reserved>
    <system value="http://hl7.org/fhir/fundsreserve"/>
    <code value="patient"/>
    <display value="Patient"/>
    <userSelected value="false"/>
  </reserved>
  <form>
    <coding>
      <system value="http://hl7.org/fhir/forms-codes"/>
      <code value="2"/>
      <display value="Form #1"/>
      <userSelected value="true"/>
    </coding>
    <text value="7x3q9RIkLbJ9UFV7oYLDzQ=="/>
  </form>
  <processNote>
    <number value="12"/>
    <type>
      <coding>
        <system value="http://hl7.org/fhir/note-type"/>
        <code value="printoper"/>
        <display value="Print (Operator)"/>
        <userSelected value="true"/>
      </coding>
      <text value="H5Q+YvhiOYCmC+EfIHf7JQ=="/>
    </type>
    <text value="8TWYlBC6EtzgDOuzE7Srcw=="/>
    <language>
      <coding>
        <system value="urn:ietf:bcp:47"/>
        <code value="el"/>
        <display value="Gr&#230;sk"/>
        <userSelected value="true"/>
      </coding>
      <text value="GgCxoYyKkQ5eS0IkUyU0KQ=="/>
    </language>
  </processNote>
  <communicationRequest>
    <identifier>
      <use value="usual"/>
      <type>
        <text value="16KbT1OS7q3aR/lMUYxoFQ=="/>
      </type>
      <system value="http://projectcrucible.org/YwumSJwIUnnICj+TFMFtyA=="/>
      <value value="GmN8Tj9JK+GFdqXHenvo8w=="/>
      <period>
        <start value="2018-01-04T11:55:10.186Z"/>
        <end value="2018-01-04T11:55:10.186Z"/>
      </period>
      <assigner>
        <display value="Organization iaZYK1Zgu4r9Z9vr4Pzipg=="/>
      </assigner>
    </identifier>
    <display value="CommunicationRequest s8OTpYf4tkBE8/oK/BP77Q=="/>
  </communicationRequest>
  <insurance>
    <sequence value="18"/>
    <focal value="false"/>
    <coverage>
      <identifier>
        <use value="official"/>
        <system value="http://projectcrucible.org/bNRvVmbJRVKkuzRVJwq0QA=="/>
        <value value="kGuj2CMZXl7y+rC1MSRFAA=="/>
      </identifier>
      <display value="Coverage +g2GVOHRZIpBEtz5X4r7kg=="/>
    </coverage>
    <businessArrangement value="3xQ4X9wFYO7mnT1cA/GyWw=="/>
    <preAuthRef value="f//FqHAtNq17pgI+uHYCCQ=="/>
    <claimResponse>
      <identifier>
        <use value="secondary"/>
        <system value="http://projectcrucible.org/j+9soCTaIQZcm4/iKAcgFw=="/>
        <value value="a6XYic+r3QQ6YPIT9cWiLA=="/>
      </identifier>
      <display value="ClaimResponse plPrajwUKgtGq0zr5SubSw=="/>
    </claimResponse>
  </insurance>
</ClaimResponse>

ClaimResponse 1 deleted

Deleted by ANONYMOUS (Unknown) at 1/4/2018 4:52:07 PM(UTC) (Audit)

ClaimResponse "4" Version "1"

Created by System at 12/18/2017 3:31:48 PM(UTC) (Audit)

Tags: (no tags)  +

This Resource , XML or JSON representation, or the full version history.. provenance for this resource
Updated: by


<?xml version="1.0" encoding="UTF-8"?>
<ClaimResponse xmlns="http://hl7.org/fhir">
  <id value="4"/>
  <meta>
    <versionId value="1"/>
    <lastUpdated value="2017-12-18T15:31:48Z"/>
  </meta>
  <identifier>
    <system value="http://localhost//claimresponses"/>
    <value value="960152"/>
  </identifier>
  <created value="2017-12-18T15:31:43Z"/>
  <request>
    <reference value="Claim/960152"/>
  </request>
  <disposition value="Automatic Response"/>
</ClaimResponse>

ClaimResponse "3" Version "1"

Created by System at 12/18/2017 3:31:13 PM(UTC) (Audit)

Tags: (no tags)  +

This Resource , XML or JSON representation, or the full version history.. provenance for this resource
Updated: by


<?xml version="1.0" encoding="UTF-8"?>
<ClaimResponse xmlns="http://hl7.org/fhir">
  <id value="3"/>
  <meta>
    <versionId value="1"/>
    <lastUpdated value="2017-12-18T15:31:13Z"/>
  </meta>
  <identifier>
    <system value="http://localhost//claimresponses"/>
    <value value="960152"/>
  </identifier>
  <created value="2017-12-18T15:31:08Z"/>
  <request>
    <reference value="Claim/960152"/>
  </request>
  <disposition value="Automatic Response"/>
</ClaimResponse>

ClaimResponse "2" Version "1"

Created by System at 12/18/2017 3:25:51 PM(UTC) (Audit)

Tags: (no tags)  +

This Resource , XML or JSON representation, or the full version history.. provenance for this resource
Updated: by


<?xml version="1.0" encoding="UTF-8"?>
<ClaimResponse xmlns="http://hl7.org/fhir">
  <id value="2"/>
  <meta>
    <versionId value="1"/>
    <lastUpdated value="2017-12-18T15:25:51Z"/>
  </meta>
  <identifier>
    <system value="http://localhost//claimresponses"/>
    <value value="960152"/>
  </identifier>
  <created value="2017-12-18T15:25:46Z"/>
  <request>
    <reference value="Claim/960152"/>
  </request>
  <disposition value="Automatic Response"/>
</ClaimResponse>

ClaimResponse "1" Version "1"

Created by System at 12/18/2017 3:17:18 PM(UTC) (Audit)

Tags: (no tags)  +

This Resource , XML or JSON representation, or the full version history.. provenance for this resource
Updated: by


<?xml version="1.0" encoding="UTF-8"?>
<ClaimResponse xmlns="http://hl7.org/fhir">
  <id value="1"/>
  <meta>
    <versionId value="1"/>
    <lastUpdated value="2017-12-18T15:17:18Z"/>
  </meta>
  <identifier>
    <system value="http://localhost//claimresponses"/>
    <value value="960152"/>
  </identifier>
  <created value="2017-12-18T15:17:13Z"/>
  <request>
    <reference value="Claim/960152"/>
  </request>
  <disposition value="Automatic Response"/>
</ClaimResponse>

ClaimResponse "R3500" Version "1"

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

Tags: (no tags)  +

This Resource , XML or JSON representation, or the full version history.. provenance for this resource
Updated: by

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>