{
  "resourceType": "ClaimResponse",
  "id": "R3500",
  "text": {
    "status": "generated",
    "div": "\u003cdiv xmlns\u003d\"http://www.w3.org/1999/xhtml\"\u003eA human-readable rendering of the ClaimResponse\u003c/div\u003e"
  },
  "identifier": [
    {
      "system": "http://www.BenefitsInc.com/fhir/remittance",
      "value": "R3500"
    }
  ],
  "status": "active",
  "type": {
    "coding": [
      {
        "system": "http://terminology.hl7.org/CodeSystem/claim-type",
        "code": "oral"
      }
    ]
  },
  "subType": {
    "coding": [
      {
        "system": "http://terminology.hl7.org/CodeSystem/ex-claimsubtype",
        "code": "emergency"
      }
    ]
  },
  "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": {
    "reference": "http://www.BenefitsInc.com/fhir/oralhealthclaim/15476332402"
  },
  "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": 135.57,
            "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": 90.47,
            "currency": "USD"
          }
        }
      ]
    }
  ],
  "total": [
    {
      "category": {
        "coding": [
          {
            "code": "submitted"
          }
        ]
      },
      "amount": {
        "value": 135.57,
        "currency": "USD"
      }
    },
    {
      "category": {
        "coding": [
          {
            "code": "benefit"
          }
        ]
      },
      "amount": {
        "value": 90.47,
        "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": "201408-2-1569478"
    }
  },
  "meta": {
    "tag": [
      {
        "system": "http://terminology.hl7.org/CodeSystem/v3-ActReason",
        "code": "HTEST",
        "display": "test health data"
      }
    ]
  }
}