{

"resourceType": "ClaimResponse",
"id": "R3501",
"identifier": [
  {
    "system": "http://www.BenefitsInc.com/fhir/remittance",
    "value": "R3501"
  }
],
"status": "active",
"type": {
  "coding": [
    {
      "system": "http://terminology.hl7.org/CodeSystem/claim-type",
      "code": "oral"
    }
  ]
},
"use": "claim",
"patient": {
  "reference": "Patient/1"
},
"created": "2014-08-16",
"insurer": {
  "identifier": {
    "system": "http://www.jurisdiction.org/insurers",
    "value": "555123"
  }
},
"requestor": {
  "reference": "Practitioner/1"
},
"request": {
  "reference": "Claim/100156"
},
"outcome": "error",
"disposition": "Claim could not be processed",
"formCode": {
  "coding": [
    {
      "system": "http://terminology.hl7.org/CodeSystem/forms-codes",
      "code": "2"
    }
  ]
},
"processNote": [
  {
    "number": 1,
    "type": "display",
    "text": "Invalid claim",
    "language": {
      "coding": [
        {
          "system": "urn:ietf:bcp:47",
          "code": "en-CA"
        }
      ]
    }
  }
],
"communicationRequest": [
  {
    "reference": "CommunicationRequest/fm-solicit"
  }
],
"error": [
  {
    "itemSequence": 3,
    "detailSequence": 2,
    "code": {
      "coding": [
        {
          "system": "http://terminology.hl7.org/CodeSystem/adjudication-error",
          "code": "a002"
        }
      ]
    }
  }
],
"meta": {
  "tag": [
    {
      "system": "http://terminology.hl7.org/CodeSystem/v3-ActReason",
      "code": "HTEST",
      "display": "test health data"
    }
  ]
}

}