FHIR Implementation Guide for ABDM
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FHIR Implementation Guide for ABDM - Local Development build (v3.0.1). See the Directory of published versions

: ClaimResponse/example-01 - XML Representation

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<ClaimResponse xmlns="http://hl7.org/fhir">
  <id value="example-01"/>
  <meta>
    <profile
             value="https://nrces.in/ndhm/fhir/r4/StructureDefinition/ClaimResponse"/>
  </meta>
  <text>
    <status value="generated"/>
    <div xmlns="http://www.w3.org/1999/xhtml"><p><b>Generated Narrative: ClaimResponse</b><a name="example-01"> </a></p><div style="display: inline-block; background-color: #d9e0e7; padding: 6px; margin: 4px; border: 1px solid #8da1b4; border-radius: 5px; line-height: 60%"><p style="margin-bottom: 0px">Resource ClaimResponse "example-01" </p><p style="margin-bottom: 0px">Profile: <a href="StructureDefinition-ClaimResponse.html">ClaimResponse</a></p></div><p><b>identifier</b>: id: R3500</p><p><b>status</b>: active</p><p><b>type</b>: Oral <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="http://terminology.hl7.org/5.0.0/CodeSystem-claim-type.html">Claim Type Codes</a>#oral)</span></p><p><b>subType</b>: Emergency Claim <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="http://terminology.hl7.org/5.0.0/CodeSystem-ex-claimsubtype.html">Example Claim SubType Codes</a>#emergency)</span></p><p><b>use</b>: claim</p><p><b>patient</b>: <a href="Patient-example-01.html">Patient/example-01</a> ""</p><p><b>created</b>: 2014-08-16</p><p><b>insurer</b>: <span></span></p><p><b>requestor</b>: <a href="Organization-example-01.html">Organization/example-01</a> "XYZ Lab Pvt.Ltd."</p><p><b>request</b>: <a href="Claim-example-01.html">Claim/example-01</a></p><p><b>outcome</b>: complete</p><p><b>disposition</b>: Claim settled as per contract.</p><p><b>payeeType</b>: Provider <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="http://terminology.hl7.org/5.0.0/CodeSystem-payeetype.html">Claim Payee Type Codes</a>#provider)</span></p><blockquote><p><b>item</b></p><p><b>itemSequence</b>: 1</p><blockquote><p><b>adjudication</b></p><p><b>category</b>: Eligible Amount <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="http://terminology.hl7.org/5.0.0/CodeSystem-adjudication.html">Adjudication Value Codes</a>#eligible)</span></p><p><b>reason</b>: Not covered <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="http://terminology.hl7.org/5.0.0/CodeSystem-adjudication-reason.html">Adjudication Reason Codes</a>#ar001)</span></p><h3>Amounts</h3><table class="grid"><tr><td>-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td>*</td><td>135.57</td><td>INR</td></tr></table></blockquote><blockquote><p><b>adjudication</b></p><p><b>category</b>: CoPay <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="http://terminology.hl7.org/5.0.0/CodeSystem-adjudication.html">Adjudication Value Codes</a>#copay)</span></p><p><b>reason</b>: Not covered <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="http://terminology.hl7.org/5.0.0/CodeSystem-adjudication-reason.html">Adjudication Reason Codes</a>#ar001)</span></p><h3>Amounts</h3><table class="grid"><tr><td>-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td>*</td><td>10.00</td><td>INR</td></tr></table></blockquote><blockquote><p><b>adjudication</b></p><p><b>category</b>: Eligible % <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="http://terminology.hl7.org/5.0.0/CodeSystem-adjudication.html">Adjudication Value Codes</a>#eligpercent)</span></p><p><b>reason</b>: Not covered <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="http://terminology.hl7.org/5.0.0/CodeSystem-adjudication-reason.html">Adjudication Reason Codes</a>#ar001)</span></p><p><b>value</b>: 80.00</p></blockquote><blockquote><p><b>adjudication</b></p><p><b>category</b>: benefit <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> ([not stated]#benefit)</span></p><p><b>reason</b>: Plan Limit Reached <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="http://terminology.hl7.org/5.0.0/CodeSystem-adjudication-reason.html">Adjudication Reason Codes</a>#ar002)</span></p><h3>Amounts</h3><table class="grid"><tr><td>-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td>*</td><td>90.47</td><td>INR</td></tr></table></blockquote></blockquote><blockquote><p><b>total</b></p><p><b>category</b>: Submitted Amount <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="http://terminology.hl7.org/5.0.0/CodeSystem-adjudication.html">Adjudication Value Codes</a>#submitted)</span></p><h3>Amounts</h3><table class="grid"><tr><td>-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td>*</td><td>135.57</td><td>INR</td></tr></table></blockquote><blockquote><p><b>total</b></p><p><b>category</b>: Benefit Amount <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="http://terminology.hl7.org/5.0.0/CodeSystem-adjudication.html">Adjudication Value Codes</a>#benefit)</span></p><h3>Amounts</h3><table class="grid"><tr><td>-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td>*</td><td>90.47</td><td>INR</td></tr></table></blockquote><blockquote><p><b>payment</b></p><p><b>type</b>: Complete <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="http://terminology.hl7.org/5.0.0/CodeSystem-ex-paymenttype.html">Example Payment Type Codes</a>#complete)</span></p><p><b>date</b>: 2014-08-31</p><h3>Amounts</h3><table class="grid"><tr><td>-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td>*</td><td>100.47</td><td>INR</td></tr></table><p><b>identifier</b>: id: 201408-2-1569478</p></blockquote></div>
  </text>
  <identifier>
    <system value="http://www.BenefitsInc.com/fhir/remittance"/>
    <value value="R3500"/>
  </identifier>
  <status value="active"/>
  <type>
    <coding>
      <system value="http://terminology.hl7.org/CodeSystem/claim-type"/>
      <code value="oral"/>
    </coding>
  </type>
  <subType>
    <coding>
      <system value="http://terminology.hl7.org/CodeSystem/ex-claimsubtype"/>
      <code value="emergency"/>
    </coding>
  </subType>
  <use value="claim"/>
  <patient>
    <reference value="Patient/example-01"/>
  </patient>
  <created value="2014-08-16"/>
  <insurer>
    <identifier>
      <system value="http://www.jurisdiction.org/insurers"/>
      <value value="555123"/>
    </identifier>
  </insurer>
  <requestor>
    <reference value="Organization/example-01"/>
  </requestor>
  <request>
    <reference value="Claim/example-01"/>
  </request>
  <outcome value="complete"/>
  <disposition value="Claim settled as per contract."/>
  <payeeType>
    <coding>
      <system value="http://terminology.hl7.org/CodeSystem/payeetype"/>
      <code value="provider"/>
    </coding>
  </payeeType>
  <item>
    <itemSequence value="1"/>
    <adjudication>
      <category>
        <coding>
          <system value="http://terminology.hl7.org/CodeSystem/adjudication"/>
          <code value="eligible"/>
        </coding>
      </category>
      <reason>
        <coding>
          <system
                  value="http://terminology.hl7.org/CodeSystem/adjudication-reason"/>
          <code value="ar001"/>
          <display value="Not covered"/>
        </coding>
      </reason>
      <amount>
        <value value="135.57"/>
        <currency value="INR"/>
      </amount>
    </adjudication>
    <adjudication>
      <category>
        <coding>
          <system value="http://terminology.hl7.org/CodeSystem/adjudication"/>
          <code value="copay"/>
        </coding>
      </category>
      <reason>
        <coding>
          <system
                  value="http://terminology.hl7.org/CodeSystem/adjudication-reason"/>
          <code value="ar001"/>
          <display value="Not covered"/>
        </coding>
      </reason>
      <amount>
        <value value="10.00"/>
        <currency value="INR"/>
      </amount>
    </adjudication>
    <adjudication>
      <category>
        <coding>
          <system value="http://terminology.hl7.org/CodeSystem/adjudication"/>
          <code value="eligpercent"/>
        </coding>
      </category>
      <reason>
        <coding>
          <system
                  value="http://terminology.hl7.org/CodeSystem/adjudication-reason"/>
          <code value="ar001"/>
          <display value="Not covered"/>
        </coding>
      </reason>
      <value value="80.00"/>
    </adjudication>
    <adjudication>
      <category>
        <coding>
          <code value="benefit"/>
        </coding>
      </category>
      <reason>
        <coding>
          <system
                  value="http://terminology.hl7.org/CodeSystem/adjudication-reason"/>
          <code value="ar002"/>
          <display value="Plan Limit Reached"/>
        </coding>
      </reason>
      <amount>
        <value value="90.47"/>
        <currency value="INR"/>
      </amount>
    </adjudication>
  </item>
  <total>
    <category>
      <coding>
        <system value="http://terminology.hl7.org/CodeSystem/adjudication"/>
        <code value="submitted"/>
      </coding>
    </category>
    <amount>
      <value value="135.57"/>
      <currency value="INR"/>
    </amount>
  </total>
  <total>
    <category>
      <coding>
        <system value="http://terminology.hl7.org/CodeSystem/adjudication"/>
        <code value="benefit"/>
      </coding>
    </category>
    <amount>
      <value value="90.47"/>
      <currency value="INR"/>
    </amount>
  </total>
  <payment>
    <type>
      <coding>
        <system value="http://terminology.hl7.org/CodeSystem/ex-paymenttype"/>
        <code value="complete"/>
      </coding>
    </type>
    <date value="2014-08-31"/>
    <amount>
      <value value="100.47"/>
      <currency value="INR"/>
    </amount>
    <identifier>
      <system value="http://www.BenefitsInc.com/fhir/paymentidentifier"/>
      <value value="201408-2-1569478"/>
    </identifier>
  </payment>
</ClaimResponse>