{

"resourceType": "ClaimResponse",
"id": "R3500",
"text": {
  "status": "generated",
  "div": "<div>A human-readable rendering of the ClaimResponse</div>"
},
"identifier": [
  {
    "system": "http://www.BenefitsInc.com/fhir/remittance",
    "value": "R3500"
  }
],
"request": {
  "reference": "http://www.BenefitsInc.com/fhir/oralhealthclaim/15476332402"
},
"created": "2014-08-16",
"organization": {
  "reference": "Organization/2"
},
"requestOrganization": {
  "reference": "Organization/1"
},
"outcome": "complete",
"disposition": "Claim settled as per contract.",
"payeeType": {
  "system": "http://hl7.org/fhir/payeetype",
  "code": "provider"
},
"item": [
  {
    "fhir_comments": [
      "  Adjudication details  "
    ],
    "sequenceLinkId": 1,
    "adjudication": [
      {
        "code": {
          "code": "eligible"
        },
        "amount": {
          "value": 135.57,
          "system": "urn:iso:std:iso:4217",
          "code": "USD"
        }
      },
      {
        "code": {
          "code": "copay"
        },
        "amount": {
          "value": 10.00,
          "system": "urn:iso:std:iso:4217",
          "code": "USD"
        }
      },
      {
        "code": {
          "code": "eligpercent"
        },
        "value": 80.00
      },
      {
        "code": {
          "code": "benefit"
        },
        "amount": {
          "value": 100.47,
          "system": "urn:iso:std:iso:4217",
          "code": "USD"
        }
      }
    ]
  }
],
"totalCost": {
  "value": 135.57,
  "system": "urn:iso:std:iso:4217",
  "code": "USD"
},
"totalBenefit": {
  "value": 100.47,
  "system": "urn:iso:std:iso:4217",
  "code": "USD"
},
"paymentDate": "2014-08-31",
"_paymentDate": {
  "fhir_comments": [
    "  Payment details  "
  ]
},
"paymentAmount": {
  "value": 100.47,
  "system": "urn:iso:std:iso:4217",
  "code": "USD"
},
"paymentRef": {
  "system": "http://www.BenefitsInc.com/fhir/paymentRef",
  "value": "201408-2-1569478"
}

}