Belgian MyCareNet eTariff Profiles
1.0.0 - STU Belgium flag

Belgian MyCareNet eTariff Profiles, published by eHealth Platform. This guide is not an authorized publication; it is the continuous build for version 1.0.0 built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/hl7-be/etariff/ and changes regularly. See the Directory of published versions

: ex11 - XML Representation

Raw xml | Download


<Bundle xmlns="http://hl7.org/fhir">
  <id value="ex11"/>
  <meta>
    <profile
             value="https://www.ehealth.fgov.be/standards/fhir/etariff/StructureDefinition/be-etariff-response"/>
  </meta>
  <type value="message"/>
  <timestamp value="2015-07-14T11:15:37+02:00"/>
  <entry>
    <fullUrl value="urn:uuid:667b18ce-3d37-4581-9baa-6fada338038c"/>
    <resource>
      <MessageHeader>
        <id value="667b18ce-3d37-4581-9baa-6fada338038c"/>
        <meta>
          <profile
                   value="https://www.ehealth.fgov.be/standards/fhir/mycarenet/StructureDefinition/be-messageheader"/>
        </meta>
        <text>
          <status value="generated"/>
          <div xmlns="http://www.w3.org/1999/xhtml"><a name="MessageHeader_667b18ce-3d37-4581-9baa-6fada338038c"> </a><p class="res-header-id"><b>Generated Narrative: MessageHeader 667b18ce-3d37-4581-9baa-6fada338038c</b></p><a name="667b18ce-3d37-4581-9baa-6fada338038c"> </a><a name="hc667b18ce-3d37-4581-9baa-6fada338038c"> </a><a name="667b18ce-3d37-4581-9baa-6fada338038c-en-US"> </a><p><b>event</b>: <a href="https://build.fhir.org/ig/hl7-be/mycarenet/CodeSystem-message-events.html#message-events-etariffresponse-consult">CodeSystem message events</a> etariffresponse-consult: etariffresponse-consult</p><h3>Destinations</h3><table class="grid"><tr><td style="display: none">-</td><td><b>Endpoint</b></td><td><b>Receiver</b></td></tr><tr><td style="display: none">*</td><td>urn:be:fgov:person:ssin:ehealth:1.0:dentist:nihii11:30202929001</td><td><a href="Bundle-ex02.html#urn-uuid-1dc5d974-5447-4afe-a4ab-57081ca518c3">Bundle: type = message; timestamp = 2015-07-14 11:15:37+0200</a></td></tr></table><p><b>sender</b>: <a href="Bundle-ex02.html#urn-uuid-cfabb40d-a53f-4c56-bc19-725ea669b358">Bundle: type = message; timestamp = 2015-07-14 11:15:37+0200</a></p><h3>Sources</h3><table class="grid"><tr><td style="display: none">-</td><td><b>Endpoint</b></td></tr><tr><td style="display: none">*</td><td>urn:be:fgov:kbo-bce:organization:cbe-number:0411724220</td></tr></table><h3>Responses</h3><table class="grid"><tr><td style="display: none">-</td><td><b>Identifier</b></td><td><b>Code</b></td></tr><tr><td style="display: none">*</td><td>267b18ce-3d37-4581-9baa-6fada338038b</td><td>OK</td></tr></table><p><b>focus</b>: <a href="Bundle-ex02.html#urn-uuid-0a0d60df-0340-45a6-a493-a5d67f74d693">Bundle: type = message; timestamp = 2015-07-14 11:15:37+0200</a></p></div>
        </text>
        <eventCoding>
          <system
                  value="https://www.ehealth.fgov.be/standards/fhir/mycarenet/CodeSystem/message-events"/>
          <code value="etariffresponse-consult"/>
        </eventCoding>
        <destination>
          <endpoint
                    value="urn:be:fgov:person:ssin:ehealth:1.0:dentist:nihii11:30202929001"/>
          <receiver>
            <reference value="urn:uuid:1dc5d974-5447-4afe-a4ab-57081ca518c3"/>
          </receiver>
        </destination>
        <sender>
          <reference value="urn:uuid:cfabb40d-a53f-4c56-bc19-725ea669b358"/>
        </sender>
        <source>
          <endpoint
                    value="urn:be:fgov:kbo-bce:organization:cbe-number:0411724220"/>
        </source>
        <response>
          <identifier value="267b18ce-3d37-4581-9baa-6fada338038b"/>
          <code value="ok"/>
        </response>
        <focus>
          <reference value="urn:uuid:0a0d60df-0340-45a6-a493-a5d67f74d693"/>
        </focus>
      </MessageHeader>
    </resource>
  </entry>
  <entry>
    <fullUrl value="urn:uuid:1dc5d974-5447-4afe-a4ab-57081ca518c3"/>
    <resource>
      <PractitionerRole>
        <id value="1dc5d974-5447-4afe-a4ab-57081ca518c3"/>
        <meta>
          <profile
                   value="https://www.ehealth.fgov.be/standards/fhir/core/StructureDefinition/be-practitionerrole"/>
        </meta>
        <text>
          <status value="generated"/>
          <div xmlns="http://www.w3.org/1999/xhtml"><a name="PractitionerRole_1dc5d974-5447-4afe-a4ab-57081ca518c3"> </a><p class="res-header-id"><b>Generated Narrative: PractitionerRole 1dc5d974-5447-4afe-a4ab-57081ca518c3</b></p><a name="1dc5d974-5447-4afe-a4ab-57081ca518c3"> </a><a name="hc1dc5d974-5447-4afe-a4ab-57081ca518c3"> </a><a name="1dc5d974-5447-4afe-a4ab-57081ca518c3-en-US"> </a><p><b>practitioner</b>: <a href="Bundle-ex01.html#urn-uuid-03972cc4-d781-4285-8d79-0f05810e1931">Bundle: type = message; timestamp = 2015-07-14 11:15:33+0200</a></p><p><b>code</b>: <span title="Codes:{https://www.ehealth.fgov.be/standards/fhir/core/CodeSystem/cd-hcparty persdentist}">dentist</span></p></div>
        </text>
        <practitioner>
          <reference value="urn:uuid:03972cc4-d781-4285-8d79-0f05810e1931"/>
        </practitioner>
        <code>
          <coding>
            <system
                    value="https://www.ehealth.fgov.be/standards/fhir/core/CodeSystem/cd-hcparty"/>
            <code value="persdentist"/>
          </coding>
        </code>
      </PractitionerRole>
    </resource>
  </entry>
  <entry>
    <fullUrl value="urn:uuid:03972cc4-d781-4285-8d79-0f05810e1931"/>
    <resource>
      <Practitioner>
        <id value="03972cc4-d781-4285-8d79-0f05810e1931"/>
        <meta>
          <profile
                   value="https://www.ehealth.fgov.be/standards/fhir/core/StructureDefinition/be-practitioner"/>
        </meta>
        <text>
          <status value="generated"/>
          <div xmlns="http://www.w3.org/1999/xhtml"><a name="Practitioner_03972cc4-d781-4285-8d79-0f05810e1931"> </a><p class="res-header-id"><b>Generated Narrative: Practitioner 03972cc4-d781-4285-8d79-0f05810e1931</b></p><a name="03972cc4-d781-4285-8d79-0f05810e1931"> </a><a name="hc03972cc4-d781-4285-8d79-0f05810e1931"> </a><a name="03972cc4-d781-4285-8d79-0f05810e1931-en-US"> </a><p><b>identifier</b>: <a href="https://build.fhir.org/ig/hl7-be/core/NamingSystem-be-nihdi.html" title="RIZIV/INAMI">BeNIHDINamingSystem</a>/30202929001</p><p><b>name</b>: Pierre Durand </p></div>
        </text>
        <identifier>
          <system
                  value="https://www.ehealth.fgov.be/standards/fhir/core/NamingSystem/nihdi"/>
          <value value="30202929001"/>
        </identifier>
        <name>
          <family value="Durand"/>
          <given value="Pierre"/>
        </name>
      </Practitioner>
    </resource>
  </entry>
  <entry>
    <fullUrl value="urn:uuid:cfabb40d-a53f-4c56-bc19-725ea669b358"/>
    <resource>
      <Organization>
        <id value="cfabb40d-a53f-4c56-bc19-725ea669b358"/>
        <meta>
          <profile
                   value="https://www.ehealth.fgov.be/standards/fhir/core/StructureDefinition/be-organization"/>
        </meta>
        <text>
          <status value="generated"/>
          <div xmlns="http://www.w3.org/1999/xhtml"><a name="Organization_cfabb40d-a53f-4c56-bc19-725ea669b358"> </a><p class="res-header-id"><b>Generated Narrative: Organization cfabb40d-a53f-4c56-bc19-725ea669b358</b></p><a name="cfabb40d-a53f-4c56-bc19-725ea669b358"> </a><a name="hccfabb40d-a53f-4c56-bc19-725ea669b358"> </a><a name="cfabb40d-a53f-4c56-bc19-725ea669b358-en-US"> </a><p><b>identifier</b>: <a href="https://build.fhir.org/ig/hl7-be/core/NamingSystem-be-insurancenumber.html" title="the identification number of a mutual insurance association (mutualité) as “a not-for-profit association, which, with foresight, assistance and solidarity aims to promote the physical, mental and social well-being of its members” (The Belgian law of 6 August 1990)">BeInsuranceNumberNamingSystem</a>/300</p><p><b>name</b>: Union Nationale des Mutualités Socialistes - Nationaal Verbond van de Socialistische Mutualiteiten</p></div>
        </text>
        <identifier>
          <system
                  value="https://www.ehealth.fgov.be/standards/fhir/core/NamingSystem/insurancenumber"/>
          <value value="300"/>
        </identifier>
        <name
              value="Union Nationale des Mutualités Socialistes - Nationaal Verbond van de Socialistische Mutualiteiten"/>
      </Organization>
    </resource>
  </entry>
  <entry>
    <fullUrl value="urn:uuid:a52efcb6-1f81-4333-a115-d45bd3183686"/>
    <resource>
      <Patient>
        <id value="a52efcb6-1f81-4333-a115-d45bd3183686"/>
        <meta>
          <profile
                   value="https://www.ehealth.fgov.be/standards/fhir/core/StructureDefinition/be-patient"/>
        </meta>
        <text>
          <status value="generated"/>
          <div xmlns="http://www.w3.org/1999/xhtml"><a name="Patient_a52efcb6-1f81-4333-a115-d45bd3183686"> </a><p class="res-header-id"><b>Generated Narrative: Patient a52efcb6-1f81-4333-a115-d45bd3183686</b></p><a name="a52efcb6-1f81-4333-a115-d45bd3183686"> </a><a name="hca52efcb6-1f81-4333-a115-d45bd3183686"> </a><a name="a52efcb6-1f81-4333-a115-d45bd3183686-en-US"> </a><p style="border: 1px #661aff solid; background-color: #e6e6ff; padding: 10px;">Jean Dupont  Male, DoB Unknown ( https://www.ehealth.fgov.be/standards/fhir/core/NamingSystem/ssin#BeSSINNamingSystem#70319666960)</p><hr/><table class="grid"><tr><td style="background-color: #f3f5da" title="Other Id (see the one above)">Other Id:</td><td colspan="3"><a href="https://build.fhir.org/ig/hl7-be/core/NamingSystem-be-insurancymembership.html" title="Membership number of a patient with an insurance organization">BeInsurancymembershipNamingSystem</a>/1234567890123</td></tr></table></div>
        </text>
        <identifier>
          <system
                  value="https://www.ehealth.fgov.be/standards/fhir/core/NamingSystem/ssin"/>
          <value value="70319666960"/>
        </identifier>
        <identifier>
          <system
                  value="https://www.ehealth.fgov.be/standards/fhir/core/NamingSystem/insurancymembership"/>
          <value value="1234567890123"/>
          <assigner>
            <identifier>
              <system
                      value="https://www.ehealth.fgov.be/standards/fhir/core/NamingSystem/insurancenumber"/>
              <value value="301"/>
            </identifier>
          </assigner>
        </identifier>
        <name>
          <family value="Dupont"/>
          <given value="Jean"/>
        </name>
        <gender value="male"/>
      </Patient>
    </resource>
  </entry>
  <entry>
    <fullUrl value="urn:uuid:5330da7f-db68-4380-a265-d364aeed8653"/>
    <resource>
      <Coverage>
        <id value="5330da7f-db68-4380-a265-d364aeed8653"/>
        <meta>
          <profile
                   value="https://www.ehealth.fgov.be/standards/fhir/mycarenet/StructureDefinition/be-mycarenet-coverage"/>
        </meta>
        <text>
          <status value="generated"/>
          <div xmlns="http://www.w3.org/1999/xhtml"><a name="Coverage_5330da7f-db68-4380-a265-d364aeed8653"> </a><p class="res-header-id"><b>Generated Narrative: Coverage 5330da7f-db68-4380-a265-d364aeed8653</b></p><a name="5330da7f-db68-4380-a265-d364aeed8653"> </a><a name="hc5330da7f-db68-4380-a265-d364aeed8653"> </a><a name="5330da7f-db68-4380-a265-d364aeed8653-en-US"> </a><p><b>status</b>: Active</p><p><b>type</b>: <span title="Codes:{http://terminology.hl7.org/CodeSystem/v3-ActCode PUBLICPOL}">public healthcare</span></p><p><b>beneficiary</b>: <a href="Bundle-ex01.html#urn-uuid-a52efcb6-1f81-4333-a115-d45bd3183686">Bundle: type = message; timestamp = 2015-07-14 11:15:33+0200</a></p><p><b>payor</b>: <a href="Bundle-ex02.html#urn-uuid-cfabb40d-a53f-4c56-bc19-725ea669b358">Bundle: type = message; timestamp = 2015-07-14 11:15:37+0200</a></p><blockquote><p><b>class</b></p><p><b>type</b>: <span title="Codes:{http://terminology.hl7.org/CodeSystem/coverage-class plan}">Plan</span></p><p><b>value</b>: Mandatory Health Insurance</p></blockquote><blockquote><p><b>class</b></p><p><b>type</b>: <span title="Codes:{http://terminology.hl7.org/CodeSystem/coverage-class subplan}">SubPlan</span></p><p><b>value</b>: 110</p></blockquote><blockquote><p><b>class</b></p><p><b>type</b>: <span title="Codes:{http://terminology.hl7.org/CodeSystem/coverage-class subplan}">SubPlan</span></p><p><b>value</b>: 150</p></blockquote></div>
        </text>
        <status value="active"/>
        <type>
          <coding>
            <system value="http://terminology.hl7.org/CodeSystem/v3-ActCode"/>
            <code value="PUBLICPOL"/>
          </coding>
        </type>
        <beneficiary>
          <reference value="urn:uuid:a52efcb6-1f81-4333-a115-d45bd3183686"/>
        </beneficiary>
        <payor>
          <reference value="urn:uuid:cfabb40d-a53f-4c56-bc19-725ea669b358"/>
        </payor>
        <class>
          <type>
            <coding>
              <system
                      value="http://terminology.hl7.org/CodeSystem/coverage-class"/>
              <code value="plan"/>
            </coding>
          </type>
          <value value="Mandatory Health Insurance"/>
        </class>
        <class>
          <type>
            <coding>
              <system
                      value="http://terminology.hl7.org/CodeSystem/coverage-class"/>
              <code value="subplan"/>
            </coding>
          </type>
          <value value="110">
            <extension
                       url="https://www.ehealth.fgov.be/standards/fhir/mycarenet/StructureDefinition/be-ext-system">
              <valueUri
                        value="https://www.ehealth.fgov.be/standards/fhir/mycarenet/CodeSystem/be-cs-holder-code-1"/>
            </extension>
          </value>
        </class>
        <class>
          <type>
            <coding>
              <system
                      value="http://terminology.hl7.org/CodeSystem/coverage-class"/>
              <code value="subplan"/>
            </coding>
          </type>
          <value value="150">
            <extension
                       url="https://www.ehealth.fgov.be/standards/fhir/mycarenet/StructureDefinition/be-ext-system">
              <valueUri
                        value="https://www.ehealth.fgov.be/standards/fhir/mycarenet/CodeSystem/be-cs-holder-code-2"/>
            </extension>
          </value>
        </class>
      </Coverage>
    </resource>
  </entry>
  <entry>
    <fullUrl value="urn:uuid:0a0d60df-0340-45a6-a493-a5d67f74d693"/>
    <resource>
      <ClaimResponse>
        <id value="0a0d60df-0340-45a6-a493-a5d67f74d693"/>
        <meta>
          <profile
                   value="https://www.ehealth.fgov.be/standards/fhir/etariff/StructureDefinition/be-etariff-claimresponse"/>
        </meta>
        <text>
          <status value="extensions"/>
          <div xmlns="http://www.w3.org/1999/xhtml"><a name="ClaimResponse_0a0d60df-0340-45a6-a493-a5d67f74d693"> </a><p class="res-header-id"><b>Generated Narrative: ClaimResponse 0a0d60df-0340-45a6-a493-a5d67f74d693</b></p><a name="0a0d60df-0340-45a6-a493-a5d67f74d693"> </a><a name="hc0a0d60df-0340-45a6-a493-a5d67f74d693"> </a><a name="0a0d60df-0340-45a6-a493-a5d67f74d693-en-US"> </a><p><b>status</b>: Active</p><p><b>type</b>: <span title="Codes:{http://terminology.hl7.org/CodeSystem/claim-type professional}">Professional</span></p><p><b>subType</b>: <span title="Codes:{https://www.ehealth.fgov.be/standards/fhir/etariff/CodeSystem/be-cs-etariff-types dentistry}">dentistry</span></p><p><b>use</b>: Predetermination</p><p><b>patient</b>: <a href="Bundle-ex01.html#urn-uuid-a52efcb6-1f81-4333-a115-d45bd3183686">Bundle: type = message; timestamp = 2015-07-14 11:15:33+0200</a></p><p><b>created</b>: 2015-07-14 11:15:30+0200</p><p><b>insurer</b>: <a href="Bundle-ex02.html#urn-uuid-cfabb40d-a53f-4c56-bc19-725ea669b358">Bundle: type = message; timestamp = 2015-07-14 11:15:37+0200</a></p><p><b>requestor</b>: <a href="Bundle-ex02.html#urn-uuid-1dc5d974-5447-4afe-a4ab-57081ca518c3">Bundle: type = message; timestamp = 2015-07-14 11:15:37+0200</a></p><p><b>outcome</b>: Processing Complete</p><blockquote><p><b>addItem</b></p><p><b>BeExtItemReimbursement</b>: <span title="Euro">€15.00</span> (EUR)</p><p><b>BeExtItemPatientFee</b>: <span title="Euro">€10.00</span> (EUR)</p><p><b>BeExtEtariffItemCommitment</b>: 123456789012345678901234567890120000000000002000</p><p><b>itemSequence</b>: 1</p><p><b>provider</b>: <a href="Bundle-ex02.html#urn-uuid-1dc5d974-5447-4afe-a4ab-57081ca518c3">Bundle: type = message; timestamp = 2015-07-14 11:15:37+0200</a></p><p><b>productOrService</b>: <span title="Codes:{https://www.ehealth.fgov.be/standards/fhir/core/NamingSystem/be-ns-nihdi-nomenclature 373590}">373590</span></p><p><b>serviced</b>: 2013-01-12</p><p><b>quantity</b>: 1</p><h3>UnitPrices</h3><table class="grid"><tr><td style="display: none">-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td style="display: none">*</td><td>25</td><td>Euro</td></tr></table><h3>Nets</h3><table class="grid"><tr><td style="display: none">-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td style="display: none">*</td><td>25</td><td>Euro</td></tr></table><h3>Adjudications</h3><table class="grid"><tr><td style="display: none">-</td><td><b>Category</b></td></tr><tr><td style="display: none">*</td><td><span title="Codes:{https://www.ehealth.fgov.be/standards/fhir/mycarenet/CodeSystem/decision-values tariff}">tariff</span></td></tr></table></blockquote><blockquote><p><b>addItem</b></p><p><b>itemSequence</b>: 2</p><p><b>provider</b>: <a href="Bundle-ex02.html#urn-uuid-1dc5d974-5447-4afe-a4ab-57081ca518c3">Bundle: type = message; timestamp = 2015-07-14 11:15:37+0200</a></p><p><b>productOrService</b>: <span title="Codes:{https://www.ehealth.fgov.be/standards/fhir/core/NamingSystem/be-ns-nihdi-nomenclature 302153}">302153</span></p><h3>Adjudications</h3><table class="grid"><tr><td style="display: none">-</td><td><b>Extension</b></td><td><b>Category</b></td><td><b>Reason</b></td></tr><tr><td style="display: none">*</td><td>, </td><td><span title="Codes:{https://www.ehealth.fgov.be/standards/fhir/mycarenet/CodeSystem/decision-values refusal}">refusal</span></td><td><span title="Codes:{https://www.ehealth.fgov.be/standards/fhir/etariff/CodeSystem/be-cs-refusal-values 002}">Maximum number of services already reached over the authorized period (and/or no derogation granted)</span></td></tr></table></blockquote><h3>Insurances</h3><table class="grid"><tr><td style="display: none">-</td><td><b>Sequence</b></td><td><b>Focal</b></td><td><b>Coverage</b></td></tr><tr><td style="display: none">*</td><td>1</td><td>true</td><td><a href="Bundle-ex02.html#urn-uuid-5330da7f-db68-4380-a265-d364aeed8653">Bundle: type = message; timestamp = 2015-07-14 11:15:37+0200</a></td></tr></table></div>
        </text>
        <status value="active"/>
        <type>
          <coding>
            <system value="http://terminology.hl7.org/CodeSystem/claim-type"/>
            <code value="professional"/>
          </coding>
        </type>
        <subType>
          <!--  attestationType  -->
          <coding>
            <system
                    value="https://www.ehealth.fgov.be/standards/fhir/etariff/CodeSystem/be-cs-etariff-types"/>
            <code value="dentistry"/>
          </coding>
        </subType>
        <use value="predetermination"/>
        <patient>
          <reference value="urn:uuid:a52efcb6-1f81-4333-a115-d45bd3183686"/>
        </patient>
        <created value="2015-07-14T11:15:30+02:00"/>
        <insurer>
          <reference value="urn:uuid:cfabb40d-a53f-4c56-bc19-725ea669b358"/>
        </insurer>
        <requestor>
          <reference value="urn:uuid:1dc5d974-5447-4afe-a4ab-57081ca518c3"/>
        </requestor>
        <outcome value="complete"/>
        <addItem>
          <extension
                     url="https://www.ehealth.fgov.be/standards/fhir/mycarenet/StructureDefinition/be-ext-mycarenet-item-reimbursement">
            <!--  reimbursement for item  -->
            <valueMoney>
              <value value="15.00"/>
              <currency value="EUR"/>
            </valueMoney>
          </extension>
          <extension
                     url="https://www.ehealth.fgov.be/standards/fhir/mycarenet/StructureDefinition/be-ext-mycarenet-item-patientfee">
            <!--  patientfee for item  -->
            <valueMoney>
              <value value="10.00"/>
              <currency value="EUR"/>
            </valueMoney>
          </extension>
          <extension
                     url="https://www.ehealth.fgov.be/standards/fhir/etariff/StructureDefinition/be-ext-etariff-item-commitment">
            <!--  commitment for item  -->
            <valueString
                         value="123456789012345678901234567890120000000000002000"/>
          </extension>
          <itemSequence value="1"/>
          <provider>
            <!--  healthcare provider  -->
            <reference value="urn:uuid:1dc5d974-5447-4afe-a4ab-57081ca518c3"/>
          </provider>
          <productOrService>
            <!--  service identifier for item  -->
            <coding>
              <system
                      value="https://www.ehealth.fgov.be/standards/fhir/core/NamingSystem/be-ns-nihdi-nomenclature"/>
              <code value="373590"/>
            </coding>
          </productOrService>
          <!--  date for item  -->
          <servicedDate value="2013-01-12"/>
          <!--  count for item  -->
          <quantity>
            <value value="1"/>
          </quantity>
          <unitPrice>
            <value value="25"/>
            <currency value="EUR"/>
          </unitPrice>
          <net>
            <!--  fee for item  -->
            <value value="25"/>
            <currency value="EUR"/>
          </net>
          <adjudication>
            <category>
              <coding>
                <system
                        value="https://www.ehealth.fgov.be/standards/fhir/mycarenet/CodeSystem/decision-values"/>
                <code value="tariff"/>
              </coding>
            </category>
          </adjudication>
        </addItem>
        <addItem>
          <itemSequence value="2"/>
          <provider>
            <!--  healthcare provider  -->
            <reference value="urn:uuid:1dc5d974-5447-4afe-a4ab-57081ca518c3"/>
          </provider>
          <productOrService>
            <!--  service identifier for item  -->
            <coding>
              <system
                      value="https://www.ehealth.fgov.be/standards/fhir/core/NamingSystem/be-ns-nihdi-nomenclature"/>
              <code value="302153"/>
            </coding>
          </productOrService>
          <adjudication>
            <extension
                       url="https://www.ehealth.fgov.be/standards/fhir/etariff/StructureDefinition/be-ext-etariff-adjudication-refusalserviceidentifier">
              <!--  refusal service identifier for adjudication  -->
              <valueCodeableConcept>
                <coding>
                  <system
                          value="https://www.ehealth.fgov.be/standards/fhir/core/NamingSystem/be-ns-nihdi-nomenclature"/>
                  <code value="302153"/>
                </coding>
              </valueCodeableConcept>
            </extension>
            <extension
                       url="https://www.ehealth.fgov.be/standards/fhir/etariff/StructureDefinition/be-ext-etariff-adjudication-refusalservicedate">
              <!--  refusal service date for adjudication  -->
              <valueDate value="2011-09-25"/>
            </extension>
            <category>
              <coding>
                <system
                        value="https://www.ehealth.fgov.be/standards/fhir/mycarenet/CodeSystem/decision-values"/>
                <code value="refusal"/>
              </coding>
            </category>
            <reason>
              <coding>
                <system
                        value="https://www.ehealth.fgov.be/standards/fhir/etariff/CodeSystem/be-cs-refusal-values"/>
                <code value="002"/>
              </coding>
            </reason>
          </adjudication>
        </addItem>
        <insurance>
          <sequence value="1"/>
          <focal value="true"/>
          <coverage>
            <reference value="urn:uuid:5330da7f-db68-4380-a265-d364aeed8653"/>
          </coverage>
        </insurance>
      </ClaimResponse>
    </resource>
  </entry>
</Bundle>