{
  "resourceType": "ClaimResponse",
  "id": "R3503",
  "text": {
    "status": "generated",
    "div": "\u003cdiv xmlns\u003d\"http://www.w3.org/1999/xhtml\"\u003eA human-readable rendering of the ClaimResponse to Claim Oral Average with additional items\u003c/div\u003e"
  },
  "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",
  "subject": {
    "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": 0.00,
            "currency": "USD"
          }
        },
        {
          "category": {
            "coding": [
              {
                "code": "benefit"
              }
            ]
          },
          "amount": {
            "value": 0.00,
            "currency": "USD"
          }
        }
      ]
    },
    {
      "itemSequence": 2,
      "adjudication": [
        {
          "category": {
            "coding": [
              {
                "code": "eligible"
              }
            ]
          },
          "amount": {
            "value": 105.00,
            "currency": "USD"
          }
        },
        {
          "category": {
            "coding": [
              {
                "code": "eligpercent"
              }
            ]
          },
          "quantity": {
            "value": 80.00
          }
        },
        {
          "category": {
            "coding": [
              {
                "code": "benefit"
              }
            ]
          },
          "amount": {
            "value": 84.00,
            "currency": "USD"
          }
        }
      ]
    },
    {
      "itemSequence": 3,
      "adjudication": [
        {
          "category": {
            "coding": [
              {
                "code": "eligible"
              }
            ]
          },
          "amount": {
            "value": 750.00,
            "currency": "USD"
          }
        },
        {
          "category": {
            "coding": [
              {
                "code": "eligpercent"
              }
            ]
          },
          "quantity": {
            "value": 80.00
          }
        },
        {
          "category": {
            "coding": [
              {
                "code": "benefit"
              }
            ]
          },
          "amount": {
            "value": 600.00,
            "currency": "USD"
          }
        }
      ],
      "detail": [
        {
          "detailSequence": 1,
          "adjudication": [
            {
              "category": {
                "coding": [
                  {
                    "code": "eligible"
                  }
                ]
              },
              "amount": {
                "value": 750.00,
                "currency": "USD"
              }
            },
            {
              "category": {
                "coding": [
                  {
                    "code": "eligpercent"
                  }
                ]
              },
              "quantity": {
                "value": 80.00
              }
            },
            {
              "category": {
                "coding": [
                  {
                    "code": "benefit"
                  }
                ]
              },
              "amount": {
                "value": 600.00,
                "currency": "USD"
              }
            }
          ]
        },
        {
          "detailSequence": 2,
          "adjudication": [
            {
              "category": {
                "coding": [
                  {
                    "code": "eligible"
                  }
                ]
              },
              "amount": {
                "value": 0.00,
                "currency": "USD"
              }
            },
            {
              "category": {
                "coding": [
                  {
                    "code": "benefit"
                  }
                ]
              },
              "amount": {
                "value": 0.00,
                "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": 100.00,
            "currency": "USD"
          }
        },
        {
          "category": {
            "coding": [
              {
                "code": "copay"
              }
            ]
          },
          "amount": {
            "value": 10.00,
            "currency": "USD"
          }
        },
        {
          "category": {
            "coding": [
              {
                "code": "eligpercent"
              }
            ]
          },
          "quantity": {
            "value": 80.00
          }
        },
        {
          "category": {
            "coding": [
              {
                "code": "benefit"
              }
            ]
          },
          "reason": {
            "coding": [
              {
                "system": "http://terminology.hl7.org/CodeSystem/adjudication-reason",
                "code": "ar002",
                "display": "Plan Limit Reached"
              }
            ]
          },
          "amount": {
            "value": 72.00,
            "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"
              }
            ]
          },
          "quantity": {
            "value": 80.00
          }
        },
        {
          "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": 350.00,
        "currency": "USD"
      },
      "noteNumber": [
        101
      ],
      "adjudication": [
        {
          "category": {
            "coding": [
              {
                "code": "eligible"
              }
            ]
          },
          "amount": {
            "value": 350.00,
            "currency": "USD"
          }
        },
        {
          "category": {
            "coding": [
              {
                "code": "eligpercent"
              }
            ]
          },
          "quantity": {
            "value": 80.00
          }
        },
        {
          "category": {
            "coding": [
              {
                "code": "benefit"
              }
            ]
          },
          "amount": {
            "value": 270.00,
            "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": {
        "coding": [
          {
            "system": "http://hl7.org/fhir/note-type",
            "code": "print"
          }
        ]
      },
      "text": "Package codes are not permitted. Codes replaced by Insurer.",
      "language": {
        "coding": [
          {
            "system": "urn:ietf:bcp:47",
            "code": "en-CA"
          }
        ]
      }
    }
  ],
  "meta": {
    "tag": [
      {
        "system": "http://terminology.hl7.org/CodeSystem/v3-ActReason",
        "code": "HTEST",
        "display": "test health data"
      }
    ]
  }
}