{

"resourceType": "ClaimResponse",
"id": "R3502",
"identifier": [
  {
    "system": "http://thebenefitcompany.com/claimresponse",
    "value": "CR6532875367"
  }
],
"status": "active",
"type": {
  "coding": [
    {
      "system": "http://terminology.hl7.org/CodeSystem/claim-type",
      "code": "vision"
    }
  ]
},
"use": "claim",
"patient": {
  "reference": "Patient/1"
},
"created": "2014-08-16",
"insurer": {
  "reference": "Organization/2"
},
"requestor": {
  "reference": "Organization/1"
},
"request": {
  "identifier": {
    "system": "http://happysight.com/claim",
    "value": "6612346"
  }
},
"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": 235.4,
          "currency": "USD"
        }
      },
      {
        "category": {
          "coding": [
            {
              "code": "copay"
            }
          ]
        },
        "amount": {
          "value": 20.0,
          "currency": "USD"
        }
      },
      {
        "category": {
          "coding": [
            {
              "code": "eligpercent"
            }
          ]
        },
        "value": 80.0
      },
      {
        "category": {
          "coding": [
            {
              "code": "benefit"
            }
          ]
        },
        "amount": {
          "value": 172.32,
          "currency": "USD"
        }
      }
    ],
    "detail": [
      {
        "detailSequence": 1,
        "noteNumber": [
          1
        ],
        "adjudication": [
          {
            "category": {
              "coding": [
                {
                  "code": "eligible"
                }
              ]
            },
            "amount": {
              "value": 100.0,
              "currency": "USD"
            }
          },
          {
            "category": {
              "coding": [
                {
                  "code": "copay"
                }
              ]
            },
            "amount": {
              "value": 20.0,
              "currency": "USD"
            }
          },
          {
            "category": {
              "coding": [
                {
                  "code": "eligpercent"
                }
              ]
            },
            "value": 80.0
          },
          {
            "category": {
              "coding": [
                {
                  "code": "benefit"
                }
              ]
            },
            "amount": {
              "value": 80.0,
              "currency": "USD"
            }
          }
        ]
      },
      {
        "detailSequence": 2,
        "noteNumber": [
          1
        ],
        "adjudication": [
          {
            "category": {
              "coding": [
                {
                  "code": "eligible"
                }
              ]
            },
            "amount": {
              "value": 110.0,
              "currency": "USD"
            }
          },
          {
            "category": {
              "coding": [
                {
                  "code": "eligpercent"
                }
              ]
            },
            "value": 80.0
          },
          {
            "category": {
              "coding": [
                {
                  "code": "benefit"
                }
              ]
            },
            "amount": {
              "value": 88.0,
              "currency": "USD"
            }
          }
        ],
        "subDetail": [
          {
            "subDetailSequence": 1,
            "noteNumber": [
              1
            ],
            "adjudication": [
              {
                "category": {
                  "coding": [
                    {
                      "code": "eligible"
                    }
                  ]
                },
                "amount": {
                  "value": 60.0,
                  "currency": "USD"
                }
              },
              {
                "category": {
                  "coding": [
                    {
                      "code": "eligpercent"
                    }
                  ]
                },
                "value": 80.0
              },
              {
                "category": {
                  "coding": [
                    {
                      "code": "benefit"
                    }
                  ]
                },
                "amount": {
                  "value": 48.0,
                  "currency": "USD"
                }
              }
            ]
          },
          {
            "subDetailSequence": 2,
            "adjudication": [
              {
                "category": {
                  "coding": [
                    {
                      "code": "eligible"
                    }
                  ]
                },
                "amount": {
                  "value": 30.0,
                  "currency": "USD"
                }
              },
              {
                "category": {
                  "coding": [
                    {
                      "code": "eligpercent"
                    }
                  ]
                },
                "value": 80.0
              },
              {
                "category": {
                  "coding": [
                    {
                      "code": "benefit"
                    }
                  ]
                },
                "amount": {
                  "value": 24.0,
                  "currency": "USD"
                }
              }
            ]
          },
          {
            "subDetailSequence": 3,
            "noteNumber": [
              1
            ],
            "adjudication": [
              {
                "category": {
                  "coding": [
                    {
                      "code": "eligible"
                    }
                  ]
                },
                "amount": {
                  "value": 10.0,
                  "currency": "USD"
                }
              },
              {
                "category": {
                  "coding": [
                    {
                      "code": "eligpercent"
                    }
                  ]
                },
                "value": 80.0
              },
              {
                "category": {
                  "coding": [
                    {
                      "code": "benefit"
                    }
                  ]
                },
                "amount": {
                  "value": 8.0,
                  "currency": "USD"
                }
              }
            ]
          }
        ]
      },
      {
        "detailSequence": 3,
        "noteNumber": [
          1
        ],
        "adjudication": [
          {
            "category": {
              "coding": [
                {
                  "code": "eligible"
                }
              ]
            },
            "amount": {
              "value": 200.0,
              "currency": "USD"
            }
          },
          {
            "category": {
              "coding": [
                {
                  "code": "eligpercent"
                }
              ]
            },
            "value": 80.0
          },
          {
            "category": {
              "coding": [
                {
                  "code": "benefit"
                }
              ]
            },
            "amount": {
              "value": 14.0,
              "currency": "USD"
            }
          }
        ]
      }
    ]
  }
],
"total": [
  {
    "category": {
      "coding": [
        {
          "code": "submitted"
        }
      ]
    },
    "amount": {
      "value": 235.4,
      "currency": "USD"
    }
  },
  {
    "category": {
      "coding": [
        {
          "code": "benefit"
        }
      ]
    },
    "amount": {
      "value": 182.0,
      "currency": "USD"
    }
  }
],
"payment": {
  "type": {
    "coding": [
      {
        "system": "http://terminology.hl7.org/CodeSystem/ex-paymenttype",
        "code": "complete"
      }
    ]
  },
  "adjustment": {
    "value": 75.0,
    "currency": "USD"
  },
  "adjustmentReason": {
    "coding": [
      {
        "system": "http://terminology.hl7.org/CodeSystem/payment-adjustment-reason",
        "code": "a002",
        "display": "Prior Overpayment"
      }
    ]
  },
  "date": "2014-08-16",
  "amount": {
    "value": 107.0,
    "currency": "USD"
  },
  "identifier": {
    "system": "http://thebenefitcompany.com/paymentidentifier",
    "value": "201416-123456"
  }
},
"processNote": [
  {
    "number": 1,
    "type": "display",
    "text": "After hours surcharge declined",
    "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"
    }
  ]
}

}