fhir-react
Version:
React component library for displaying FHIR Resources
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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",
"patient": {
"reference": "Patient/1"
},
"created": "2014-08-16",
"insurer": {
"identifier": {
"system": "http://www.jurisdiction.org/insurers",
"value": "555123"
}
},
"requestProvider": {
"reference": "Organization/1"
},
"request": {
"identifier": {
"system": "http://happyvalley.com/claim",
"value": "12346"
}
},
"outcome": "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": 0.00,
"system": "urn:iso:std:iso:4217",
"code": "USD"
}
},
{
"category": {
"coding": [
{
"code": "benefit"
}
]
},
"amount": {
"value": 0.00,
"system": "urn:iso:std:iso:4217",
"code": "USD"
}
}
]
},
{
"sequenceLinkId": 2,
"adjudication": [
{
"category": {
"coding": [
{
"code": "eligible"
}
]
},
"amount": {
"value": 105.00,
"system": "urn:iso:std:iso:4217",
"code": "USD"
}
},
{
"category": {
"coding": [
{
"code": "eligpercent"
}
]
},
"value": 80.00
},
{
"category": {
"coding": [
{
"code": "benefit"
}
]
},
"amount": {
"value": 84.00,
"system": "urn:iso:std:iso:4217",
"code": "USD"
}
}
]
},
{
"sequenceLinkId": 3,
"adjudication": [
{
"category": {
"coding": [
{
"code": "eligible"
}
]
},
"amount": {
"value": 750.00,
"system": "urn:iso:std:iso:4217",
"code": "USD"
}
},
{
"category": {
"coding": [
{
"code": "eligpercent"
}
]
},
"value": 80.00
},
{
"category": {
"coding": [
{
"code": "benefit"
}
]
},
"amount": {
"value": 600.00,
"system": "urn:iso:std:iso:4217",
"code": "USD"
}
}
],
"detail": [
{
"sequenceLinkId": 1,
"adjudication": [
{
"category": {
"coding": [
{
"code": "eligible"
}
]
},
"amount": {
"value": 750.00,
"system": "urn:iso:std:iso:4217",
"code": "USD"
}
},
{
"category": {
"coding": [
{
"code": "eligpercent"
}
]
},
"value": 80.00
},
{
"category": {
"coding": [
{
"code": "benefit"
}
]
},
"amount": {
"value": 600.00,
"system": "urn:iso:std:iso:4217",
"code": "USD"
}
}
]
},
{
"sequenceLinkId": 2,
"adjudication": [
{
"category": {
"coding": [
{
"code": "eligible"
}
]
},
"amount": {
"value": 0.00,
"system": "urn:iso:std:iso:4217",
"code": "USD"
}
},
{
"category": {
"coding": [
{
"code": "benefit"
}
]
},
"amount": {
"value": 0.00,
"system": "urn:iso:std:iso:4217",
"code": "USD"
}
}
]
}
]
}
],
"addItem": [
{
"sequenceLinkId": 1,
"service": {
"coding": [
{
"system": "http://example.org/fhir/oralservicecodes",
"code": "1101"
}
]
},
"modifier": [
{
"coding": [
{
"system": "http://example.org/fhir/modifiers",
"code": "x",
"display": "None"
}
]
}
],
"fee": {
"value": 135.57,
"system": "urn:iso:std:iso:4217",
"code": "USD"
},
"noteNumber": [
101
],
"adjudication": [
{
"category": {
"coding": [
{
"code": "eligible"
}
]
},
"amount": {
"value": 100.00,
"system": "urn:iso:std:iso:4217",
"code": "USD"
}
},
{
"category": {
"coding": [
{
"code": "copay"
}
]
},
"amount": {
"value": 10.00,
"system": "urn:iso:std:iso:4217",
"code": "USD"
}
},
{
"category": {
"coding": [
{
"code": "eligpercent"
}
]
},
"value": 80.00
},
{
"category": {
"coding": [
{
"code": "benefit"
}
]
},
"reason": {
"coding": [
{
"system": "http://hl7.org/fhir/adjudication-reason",
"code": "ar002",
"display": "Plan Limit Reached"
}
]
},
"amount": {
"value": 72.00,
"system": "urn:iso:std:iso:4217",
"code": "USD"
}
}
]
},
{
"sequenceLinkId": 2,
"service": {
"coding": [
{
"system": "http://example.org/fhir/oralservicecodes",
"code": "2141",
"display": "Radiograph, bytewing"
}
]
},
"fee": {
"value": 35.57,
"system": "urn:iso:std:iso:4217",
"code": "USD"
},
"adjudication": [
{
"category": {
"coding": [
{
"code": "eligible"
}
]
},
"amount": {
"value": 35.57,
"system": "urn:iso:std:iso:4217",
"code": "USD"
}
},
{
"category": {
"coding": [
{
"code": "eligpercent"
}
]
},
"value": 80.00
},
{
"category": {
"coding": [
{
"code": "benefit"
}
]
},
"amount": {
"value": 28.47,
"system": "urn:iso:std:iso:4217",
"code": "USD"
}
}
]
},
{
"sequenceLinkId": 3,
"service": {
"coding": [
{
"system": "http://example.org/fhir/oralservicecodes",
"code": "expense"
}
]
},
"modifier": [
{
"coding": [
{
"system": "http://example.org/fhir/modifiers",
"code": "x",
"display": "None"
}
]
}
],
"fee": {
"value": 350.00,
"system": "urn:iso:std:iso:4217",
"code": "USD"
},
"noteNumber": [
101
],
"adjudication": [
{
"category": {
"coding": [
{
"code": "eligible"
}
]
},
"amount": {
"value": 350.00,
"system": "urn:iso:std:iso:4217",
"code": "USD"
}
},
{
"category": {
"coding": [
{
"code": "eligpercent"
}
]
},
"value": 80.00
},
{
"category": {
"coding": [
{
"code": "benefit"
}
]
},
"amount": {
"value": 270.00,
"system": "urn:iso:std:iso:4217",
"code": "USD"
}
}
]
}
],
"totalCost": {
"value": 1340.57,
"system": "urn:iso:std:iso:4217",
"code": "USD"
},
"totalBenefit": {
"value": 1054.47,
"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": "201408-2-15507"
}
}
}