fhir-react
Version:
React component library for displaying FHIR Resources
514 lines (513 loc) • 10.3 kB
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{
"resourceType": "ClaimResponse",
"id": "R3503",
"text": {
"status": "generated",
"div": "<div xmlns=\"http://www.w3.org/1999/xhtml\">A human-readable rendering of the ClaimResponse to Claim Oral Average with additional items</div>"
},
"identifier": [
{
"system": "http://www.BenefitsInc.com/fhir/remittance",
"value": "R3503"
}
],
"status": "active",
"type": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/claim-type",
"code": "oral"
}
]
},
"use": "claim",
"patient": {
"reference": "Patient/1"
},
"created": "2014-08-16",
"insurer": {
"identifier": {
"system": "http://www.jurisdiction.org/insurers",
"value": "555123"
}
},
"requestor": {
"reference": "Organization/1"
},
"request": {
"identifier": {
"system": "http://happyvalley.com/claim",
"value": "12346"
}
},
"outcome": "complete",
"disposition": "Claim settled as per contract.",
"payeeType": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/payeetype",
"code": "provider"
}
]
},
"item": [
{
"itemSequence": 1,
"adjudication": [
{
"category": {
"coding": [
{
"code": "eligible"
}
]
},
"amount": {
"value": 0.0,
"currency": "USD"
}
},
{
"category": {
"coding": [
{
"code": "benefit"
}
]
},
"amount": {
"value": 0.0,
"currency": "USD"
}
}
]
},
{
"itemSequence": 2,
"adjudication": [
{
"category": {
"coding": [
{
"code": "eligible"
}
]
},
"amount": {
"value": 105.0,
"currency": "USD"
}
},
{
"category": {
"coding": [
{
"code": "eligpercent"
}
]
},
"value": 80.0
},
{
"category": {
"coding": [
{
"code": "benefit"
}
]
},
"amount": {
"value": 84.0,
"currency": "USD"
}
}
]
},
{
"itemSequence": 3,
"adjudication": [
{
"category": {
"coding": [
{
"code": "eligible"
}
]
},
"amount": {
"value": 750.0,
"currency": "USD"
}
},
{
"category": {
"coding": [
{
"code": "eligpercent"
}
]
},
"value": 80.0
},
{
"category": {
"coding": [
{
"code": "benefit"
}
]
},
"amount": {
"value": 600.0,
"currency": "USD"
}
}
],
"detail": [
{
"detailSequence": 1,
"adjudication": [
{
"category": {
"coding": [
{
"code": "eligible"
}
]
},
"amount": {
"value": 750.0,
"currency": "USD"
}
},
{
"category": {
"coding": [
{
"code": "eligpercent"
}
]
},
"value": 80.0
},
{
"category": {
"coding": [
{
"code": "benefit"
}
]
},
"amount": {
"value": 600.0,
"currency": "USD"
}
}
]
},
{
"detailSequence": 2,
"adjudication": [
{
"category": {
"coding": [
{
"code": "eligible"
}
]
},
"amount": {
"value": 0.0,
"currency": "USD"
}
},
{
"category": {
"coding": [
{
"code": "benefit"
}
]
},
"amount": {
"value": 0.0,
"currency": "USD"
}
}
]
}
]
}
],
"addItem": [
{
"itemSequence": [1],
"productOrService": {
"coding": [
{
"system": "http://example.org/fhir/oralservicecodes",
"code": "1101"
}
]
},
"modifier": [
{
"coding": [
{
"system": "http://example.org/fhir/modifiers",
"code": "x",
"display": "None"
}
]
}
],
"net": {
"value": 135.57,
"currency": "USD"
},
"noteNumber": [101],
"adjudication": [
{
"category": {
"coding": [
{
"code": "eligible"
}
]
},
"amount": {
"value": 100.0,
"currency": "USD"
}
},
{
"category": {
"coding": [
{
"code": "copay"
}
]
},
"amount": {
"value": 10.0,
"currency": "USD"
}
},
{
"category": {
"coding": [
{
"code": "eligpercent"
}
]
},
"value": 80.0
},
{
"category": {
"coding": [
{
"code": "benefit"
}
]
},
"reason": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication-reason",
"code": "ar002",
"display": "Plan Limit Reached"
}
]
},
"amount": {
"value": 72.0,
"currency": "USD"
}
}
]
},
{
"itemSequence": [1],
"productOrService": {
"coding": [
{
"system": "http://example.org/fhir/oralservicecodes",
"code": "2141",
"display": "Radiograph, bytewing"
}
]
},
"net": {
"value": 35.57,
"currency": "USD"
},
"adjudication": [
{
"category": {
"coding": [
{
"code": "eligible"
}
]
},
"amount": {
"value": 35.57,
"currency": "USD"
}
},
{
"category": {
"coding": [
{
"code": "eligpercent"
}
]
},
"value": 80.0
},
{
"category": {
"coding": [
{
"code": "benefit"
}
]
},
"amount": {
"value": 28.47,
"currency": "USD"
}
}
]
},
{
"itemSequence": [3],
"detailSequence": [2],
"productOrService": {
"coding": [
{
"system": "http://example.org/fhir/oralservicecodes",
"code": "expense"
}
]
},
"modifier": [
{
"coding": [
{
"system": "http://example.org/fhir/modifiers",
"code": "x",
"display": "None"
}
]
}
],
"net": {
"value": 350.0,
"currency": "USD"
},
"noteNumber": [101],
"adjudication": [
{
"category": {
"coding": [
{
"code": "eligible"
}
]
},
"amount": {
"value": 350.0,
"currency": "USD"
}
},
{
"category": {
"coding": [
{
"code": "eligpercent"
}
]
},
"value": 80.0
},
{
"category": {
"coding": [
{
"code": "benefit"
}
]
},
"amount": {
"value": 270.0,
"currency": "USD"
}
}
]
}
],
"total": [
{
"category": {
"coding": [
{
"code": "submitted"
}
]
},
"amount": {
"value": 1340.57,
"currency": "USD"
}
},
{
"category": {
"coding": [
{
"code": "benefit"
}
]
},
"amount": {
"value": 1054.47,
"currency": "USD"
}
}
],
"payment": {
"type": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/ex-paymenttype",
"code": "complete"
}
]
},
"date": "2014-08-31",
"amount": {
"value": 100.47,
"currency": "USD"
},
"identifier": {
"system": "http://www.BenefitsInc.com/fhir/paymentidentifier",
"value": "201408-2-15507"
}
},
"processNote": [
{
"number": 101,
"type": "print",
"text": "Package codes are not permitted. Codes replaced by Insurer.",
"language": {
"coding": [
{
"system": "urn:ietf:bcp:47",
"code": "en-CA"
}
]
}
}
]
}