{

"resourceType": "ClaimResponse",
"id": "R3500",
"identifier": [
  {
    "system": "http://www.BenefitsInc.com/fhir/remittance",
    "value": "R3500"
  }
],
"status": "active",
"type": {
  "coding": [
    {
      "system": "http://terminology.hl7.org/CodeSystem/claim-type",
      "code": "oral"
    }
  ]
},
"subType": {
  "coding": [
    {
      "system": "http://terminology.hl7.org/CodeSystem/ex-claimsubtype",
      "code": "emergency"
    }
  ]
},
"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": {
  "reference": "http://www.BenefitsInc.com/fhir/Claim/15476332402"
},
"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": 135.57,
          "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": 90.47,
          "currency": "USD"
        }
      }
    ]
  }
],
"total": [
  {
    "category": {
      "coding": [
        {
          "code": "submitted"
        }
      ]
    },
    "amount": {
      "value": 135.57,
      "currency": "USD"
    }
  },
  {
    "category": {
      "coding": [
        {
          "code": "benefit"
        }
      ]
    },
    "amount": {
      "value": 90.47,
      "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": "201408-2-1569478"
  }
},
"meta": {
  "tag": [
    {
      "system": "http://terminology.hl7.org/CodeSystem/v3-ActReason",
      "code": "HTEST",
      "display": "test health data"
    }
  ]
}

}