{

"resourceType": "ClaimResponse",
"id": "R3503",
"identifier": [
  {
    "system": "http://www.BenefitsInc.com/fhir/remittance",
    "value": "R3503"
  }
],
"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": "Organization/1"
},
"request": {
  "identifier": {
    "system": "http://happyvalley.com/claim",
    "value": "12346"
  }
},
"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": 0.0,
          "currency": "USD"
        }
      },
      {
        "category": {
          "coding": [
            {
              "code": "benefit"
            }
          ]
        },
        "amount": {
          "value": 0.0,
          "currency": "USD"
        }
      }
    ]
  },
  {
    "itemSequence": 2,
    "adjudication": [
      {
        "category": {
          "coding": [
            {
              "code": "eligible"
            }
          ]
        },
        "amount": {
          "value": 105.0,
          "currency": "USD"
        }
      },
      {
        "category": {
          "coding": [
            {
              "code": "eligpercent"
            }
          ]
        },
        "value": 80.0
      },
      {
        "category": {
          "coding": [
            {
              "code": "benefit"
            }
          ]
        },
        "amount": {
          "value": 84.0,
          "currency": "USD"
        }
      }
    ]
  },
  {
    "itemSequence": 3,
    "adjudication": [
      {
        "category": {
          "coding": [
            {
              "code": "eligible"
            }
          ]
        },
        "amount": {
          "value": 750.0,
          "currency": "USD"
        }
      },
      {
        "category": {
          "coding": [
            {
              "code": "eligpercent"
            }
          ]
        },
        "value": 80.0
      },
      {
        "category": {
          "coding": [
            {
              "code": "benefit"
            }
          ]
        },
        "amount": {
          "value": 600.0,
          "currency": "USD"
        }
      }
    ],
    "detail": [
      {
        "detailSequence": 1,
        "adjudication": [
          {
            "category": {
              "coding": [
                {
                  "code": "eligible"
                }
              ]
            },
            "amount": {
              "value": 750.0,
              "currency": "USD"
            }
          },
          {
            "category": {
              "coding": [
                {
                  "code": "eligpercent"
                }
              ]
            },
            "value": 80.0
          },
          {
            "category": {
              "coding": [
                {
                  "code": "benefit"
                }
              ]
            },
            "amount": {
              "value": 600.0,
              "currency": "USD"
            }
          }
        ]
      },
      {
        "detailSequence": 2,
        "adjudication": [
          {
            "category": {
              "coding": [
                {
                  "code": "eligible"
                }
              ]
            },
            "amount": {
              "value": 0.0,
              "currency": "USD"
            }
          },
          {
            "category": {
              "coding": [
                {
                  "code": "benefit"
                }
              ]
            },
            "amount": {
              "value": 0.0,
              "currency": "USD"
            }
          }
        ]
      }
    ]
  }
],
"addItem": [
  {
    "itemSequence": [
      1
    ],
    "productOrService": {
      "coding": [
        {
          "system": "http://example.org/fhir/oralservicecodes",
          "code": "1101"
        }
      ]
    },
    "modifier": [
      {
        "coding": [
          {
            "system": "http://example.org/fhir/modifiers",
            "code": "x",
            "display": "None"
          }
        ]
      }
    ],
    "net": {
      "value": 135.57,
      "currency": "USD"
    },
    "noteNumber": [
      101
    ],
    "adjudication": [
      {
        "category": {
          "coding": [
            {
              "code": "eligible"
            }
          ]
        },
        "amount": {
          "value": 100.0,
          "currency": "USD"
        }
      },
      {
        "category": {
          "coding": [
            {
              "code": "copay"
            }
          ]
        },
        "amount": {
          "value": 10.0,
          "currency": "USD"
        }
      },
      {
        "category": {
          "coding": [
            {
              "code": "eligpercent"
            }
          ]
        },
        "value": 80.0
      },
      {
        "category": {
          "coding": [
            {
              "code": "benefit"
            }
          ]
        },
        "reason": {
          "coding": [
            {
              "system": "http://terminology.hl7.org/CodeSystem/adjudication-reason",
              "code": "ar002",
              "display": "Plan Limit Reached"
            }
          ]
        },
        "amount": {
          "value": 72.0,
          "currency": "USD"
        }
      }
    ]
  },
  {
    "itemSequence": [
      1
    ],
    "productOrService": {
      "coding": [
        {
          "system": "http://example.org/fhir/oralservicecodes",
          "code": "2141",
          "display": "Radiograph, bytewing"
        }
      ]
    },
    "net": {
      "value": 35.57,
      "currency": "USD"
    },
    "adjudication": [
      {
        "category": {
          "coding": [
            {
              "code": "eligible"
            }
          ]
        },
        "amount": {
          "value": 35.57,
          "currency": "USD"
        }
      },
      {
        "category": {
          "coding": [
            {
              "code": "eligpercent"
            }
          ]
        },
        "value": 80.0
      },
      {
        "category": {
          "coding": [
            {
              "code": "benefit"
            }
          ]
        },
        "amount": {
          "value": 28.47,
          "currency": "USD"
        }
      }
    ]
  },
  {
    "itemSequence": [
      3
    ],
    "detailSequence": [
      2
    ],
    "productOrService": {
      "coding": [
        {
          "system": "http://example.org/fhir/oralservicecodes",
          "code": "expense"
        }
      ]
    },
    "modifier": [
      {
        "coding": [
          {
            "system": "http://example.org/fhir/modifiers",
            "code": "x",
            "display": "None"
          }
        ]
      }
    ],
    "net": {
      "value": 350.0,
      "currency": "USD"
    },
    "noteNumber": [
      101
    ],
    "adjudication": [
      {
        "category": {
          "coding": [
            {
              "code": "eligible"
            }
          ]
        },
        "amount": {
          "value": 350.0,
          "currency": "USD"
        }
      },
      {
        "category": {
          "coding": [
            {
              "code": "eligpercent"
            }
          ]
        },
        "value": 80.0
      },
      {
        "category": {
          "coding": [
            {
              "code": "benefit"
            }
          ]
        },
        "amount": {
          "value": 270.0,
          "currency": "USD"
        }
      }
    ]
  }
],
"total": [
  {
    "category": {
      "coding": [
        {
          "code": "submitted"
        }
      ]
    },
    "amount": {
      "value": 1340.57,
      "currency": "USD"
    }
  },
  {
    "category": {
      "coding": [
        {
          "code": "benefit"
        }
      ]
    },
    "amount": {
      "value": 1054.47,
      "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": "201408-2-15507"
  }
},
"processNote": [
  {
    "number": 101,
    "type": "print",
    "text": "Package codes are not permitted. Codes replaced by Insurer.",
    "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"
    }
  ]
}

}