A ClaimResponse demonstrating Payor service code substitutions (id = "R3503")

<?xml version="1.0" encoding="UTF-8"?>

<ClaimResponse xmlns="http://hl7.org/fhir">
  <id value="R3503"/> 
  <text> 
    <status value="generated"/> <div xmlns="http://www.w3.org/1999/xhtml">A human-readable rendering of the ClaimResponse to Claim Oral Average with additional
       items</div> 
  </text> 
  <identifier> 
    <system value="http://www.BenefitsInc.com/fhir/remittance"/> 
    <value value="R3503"/> 
  </identifier> 
  <status value="active"/> 
  <type> 
    <coding> 
      <system value="http://terminology.hl7.org/CodeSystem/claim-type"/> 
      <code value="oral"/> 
    </coding> 
  </type> 
  <use value="claim"/> 
  <patient> 
    <reference value="Patient/1"/> 
  </patient> 
  <created value="2014-08-16"/> 
  <insurer> 
    <identifier> 
      <system value="http://www.jurisdiction.org/insurers"/> 
      <value value="555123"/> 
    </identifier> 
  </insurer> 
  <requestor> 
    <reference value="Organization/1"/> 
  </requestor> 
  <request> 
    <identifier> 
      <system value="http://happyvalley.com/claim"/> 
      <value value="12346"/> 
    </identifier> 
  </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> 
  <!--   Adjudication details   -->
  <item> 
    <!--   Pays for a claim package code with two actual codes with adjudication details
       -->
    <itemSequence value="1"/> 
    <adjudication> 
      <category> 
        <coding> 
          <code value="eligible"/> 
        </coding> 
      </category> 
      <amount> 
        <value value="0.00"/> 
        <currency value="USD"/> 
      </amount> 
    </adjudication> 
    <adjudication> 
      <category> 
        <coding> 
          <code value="benefit"/> 
        </coding> 
      </category> 
      <amount> 
        <value value="0.00"/> 
        <currency value="USD"/> 
      </amount> 
    </adjudication> 
  </item> 
  <item> 
    <itemSequence value="2"/> 
    <adjudication> 
      <category> 
        <coding> 
          <code value="eligible"/> 
        </coding> 
      </category> 
      <amount> 
        <value value="105.00"/> 
        <currency value="USD"/> 
      </amount> 
    </adjudication> 
    <adjudication> 
      <category> 
        <coding> 
          <code value="eligpercent"/> 
        </coding> 
      </category> 
      <quantity> 
        <value value="80.00"/> 
      </quantity> 
    </adjudication> 
    <adjudication> 
      <category> 
        <coding> 
          <code value="benefit"/> 
        </coding> 
      </category> 
      <amount> 
        <value value="84.00"/> 
        <currency value="USD"/> 
      </amount> 
    </adjudication> 
  </item> 
  <item> 
    <itemSequence value="3"/> 
    <adjudication> 
      <category> 
        <coding> 
          <code value="eligible"/> 
        </coding> 
      </category> 
      <amount> 
        <value value="750.00"/> 
        <currency value="USD"/> 
      </amount> 
    </adjudication> 
    <adjudication> 
      <category> 
        <coding> 
          <code value="eligpercent"/> 
        </coding> 
      </category> 
      <quantity> 
        <value value="80.00"/> 
      </quantity> 
    </adjudication> 
    <adjudication> 
      <category> 
        <coding> 
          <code value="benefit"/> 
        </coding> 
      </category> 
      <amount> 
        <value value="600.00"/> 
        <currency value="USD"/> 
      </amount> 
    </adjudication> 
    <detail> 
      <detailSequence value="1"/> 
      <adjudication> 
        <category> 
          <coding> 
            <code value="eligible"/> 
          </coding> 
        </category> 
        <amount> 
          <value value="750.00"/> 
          <currency value="USD"/> 
        </amount> 
      </adjudication> 
      <adjudication> 
        <category> 
          <coding> 
            <code value="eligpercent"/> 
          </coding> 
        </category> 
        <quantity> 
          <value value="80.00"/> 
        </quantity> 
      </adjudication> 
      <adjudication> 
        <category> 
          <coding> 
            <code value="benefit"/> 
          </coding> 
        </category> 
        <amount> 
          <value value="600.00"/> 
          <currency value="USD"/> 
        </amount> 
      </adjudication> 
    </detail> 
    <detail> 
      <!--   See the addItem.detail below   -->
      <detailSequence value="2"/> 
      <adjudication> 
        <category> 
          <coding> 
            <code value="eligible"/> 
          </coding> 
        </category> 
        <amount> 
          <value value="0.00"/> 
          <currency value="USD"/> 
        </amount> 
      </adjudication> 
      <adjudication> 
        <category> 
          <coding> 
            <code value="benefit"/> 
          </coding> 
        </category> 
        <amount> 
          <value value="0.00"/> 
          <currency value="USD"/> 
        </amount> 
      </adjudication> 
    </detail> 
  </item> 
  <!--   Pays for a claim package code (1200) with two actual codes (1101, 2141) with
   adjudication details   -->
  <addItem> 
    <itemSequence value="1"/> 
    <productOrService> 
      <coding> 
        <system value="http://example.org/fhir/oralservicecodes"/> 
        <code value="1101"/> 
      </coding> 
    </productOrService> 
    <modifier> 
      <coding> 
        <system value="http://example.org/fhir/modifiers"/> 
        <code value="x"/> 
        <display value="None"/> 
      </coding> 
    </modifier> 
    <net> 
      <value value="135.57"/> 
      <currency value="USD"/> 
    </net> 
    <noteNumber value="101"/> 
    <adjudication> 
      <category> 
        <coding> 
          <code value="eligible"/> 
        </coding> 
      </category> 
      <amount> 
        <value value="100.00"/> 
        <currency value="USD"/> 
      </amount> 
    </adjudication> 
    <adjudication> 
      <category> 
        <coding> 
          <code value="copay"/> 
        </coding> 
      </category> 
      <amount> 
        <value value="10.00"/> 
        <currency value="USD"/> 
      </amount> 
    </adjudication> 
    <adjudication> 
      <category> 
        <coding> 
          <code value="eligpercent"/> 
        </coding> 
      </category> 
      <quantity> 
        <value value="80.00"/> 
      </quantity> 
    </adjudication> 
    <adjudication> 
      <category> 
        <coding> 
          <code value="benefit"/> 
        </coding> 
      </category> 
      <reason> 
        <!--   should have paid 100.47   -->
        <coding> 
          <system value="http://terminology.hl7.org/CodeSystem/adjudication-reason"/> 
          <code value="ar002"/> 
          <display value="Plan Limit Reached"/> 
        </coding> 
      </reason> 
      <amount> 
        <value value="72.00"/> 
        <currency value="USD"/> 
      </amount> 
    </adjudication> 
  </addItem> 
  <addItem> 
    <itemSequence value="1"/> 
    <productOrService> 
      <coding> 
        <system value="http://example.org/fhir/oralservicecodes"/> 
        <code value="2141"/> 
        <display value="Radiograph, bytewing"/> 
      </coding> 
    </productOrService> 
    <net> 
      <value value="35.57"/> 
      <currency value="USD"/> 
    </net> 
    <adjudication> 
      <category> 
        <coding> 
          <code value="eligible"/> 
        </coding> 
      </category> 
      <amount> 
        <value value="35.57"/> 
        <currency value="USD"/> 
      </amount> 
    </adjudication> 
    <adjudication> 
      <category> 
        <coding> 
          <code value="eligpercent"/> 
        </coding> 
      </category> 
      <quantity> 
        <value value="80.00"/> 
      </quantity> 
    </adjudication> 
    <adjudication> 
      <category> 
        <coding> 
          <code value="benefit"/> 
        </coding> 
      </category> 
      <amount> 
        <value value="28.47"/> 
        <currency value="USD"/> 
      </amount> 
    </adjudication> 
  </addItem> 
  <!--   Pays for a claim package code (1200) with two actual codes (1101, 2141) with
   adjudication details   -->
  <addItem> 
    <itemSequence value="3"/> 
    <detailSequence value="2"/> 
    <productOrService> 
      <coding> 
        <system value="http://example.org/fhir/oralservicecodes"/> 
        <code value="expense"/> 
      </coding> 
    </productOrService> 
    <modifier> 
      <coding> 
        <system value="http://example.org/fhir/modifiers"/> 
        <code value="x"/> 
        <display value="None"/> 
      </coding> 
    </modifier> 
    <net> 
      <value value="350.00"/> 
      <currency value="USD"/> 
    </net> 
    <noteNumber value="101"/> 
    <adjudication> 
      <category> 
        <coding> 
          <code value="eligible"/> 
        </coding> 
      </category> 
      <amount> 
        <value value="350.00"/> 
        <currency value="USD"/> 
      </amount> 
    </adjudication> 
    <adjudication> 
      <category> 
        <coding> 
          <code value="eligpercent"/> 
        </coding> 
      </category> 
      <quantity> 
        <value value="80.00"/> 
      </quantity> 
    </adjudication> 
    <adjudication> 
      <category> 
        <coding> 
          <code value="benefit"/> 
        </coding> 
      </category> 
      <amount> 
        <value value="270.00"/> 
        <currency value="USD"/> 
      </amount> 
    </adjudication> 
  </addItem> 
  <total> 
    <category> 
      <coding> 
        <code value="submitted"/> 
      </coding> 
    </category> 
    <amount> 
      <value value="1340.57"/> 
      <currency value="USD"/> 
    </amount> 
  </total> 
  <total> 
    <category> 
      <coding> 
        <code value="benefit"/> 
      </coding> 
    </category> 
    <amount> 
      <value value="1054.47"/> 
      <currency value="USD"/> 
    </amount> 
  </total> 
  <!--   Payment details   -->
  <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="USD"/> 
    </amount> 
    <identifier> 
      <system value="http://www.BenefitsInc.com/fhir/paymentidentifier"/> 
      <value value="201408-2-15507"/> 
    </identifier> 
  </payment> 
  <processNote> 
    <number value="101"/> 
    <type> 
      <coding> 
        <system value="http://hl7.org/fhir/note-type"/> 
        <code value="print"/> 
      </coding> 
    </type> 
    <text value="Package codes are not permitted. Codes replaced by Insurer."/> 
    <language> 
      <coding> 
        <system value="urn:ietf:bcp:47"/> 
        <code value="en-CA"/> 
      </coding> 
    </language> 
  </processNote> 
</ClaimResponse>