ClaimResponse

This resource provides the adjudication details from the processing of a Claim resource.

Columns

Header row
# path type required description
0 resourceType string * Resource type identifier. Must be string "ClaimResponse"
1 integer * Number of subrows
2 id string * Logical id of this artifact
3 status code active | cancelled | draft | entered-in-error
type CodeableConcept More granular claim type
type.coding Coding Code defined by a terminology system
4 type.coding.system uri Identity of the terminology system
5 type.coding.version string Version of the system - if relevant
6 type.coding.code code Symbol in syntax defined by the system
7 type.coding.display string Representation defined by the system
8 type.coding.userSelected boolean If this coding was chosen directly by the user
9 type.text string Plain text representation of the concept
subType CodeableConcept More granular claim type
subType.coding Coding Code defined by a terminology system
10 subType.coding.system uri Identity of the terminology system
11 subType.coding.version string Version of the system - if relevant
12 subType.coding.code code Symbol in syntax defined by the system
13 subType.coding.display string Representation defined by the system
14 subType.coding.userSelected boolean If this coding was chosen directly by the user
15 subType.text string Plain text representation of the concept
16 use code claim | preauthorization | predetermination
patient Reference The recipient of the products and services
17 patient.reference string Literal reference, Relative, internal or absolute URL
18 patient.type uri Type the reference refers to (e.g. "Patient")
patient.identifier Identifier Logical reference, when literal reference is not known
19 patient.identifier.use code usual | official | temp | secondary | old (If known)
patient.identifier.type CodeableConcept Description of identifier
patient.identifier.type.coding Coding Code defined by a terminology system
20 patient.identifier.type.coding.system uri Identity of the terminology system
21 patient.identifier.type.coding.version string Version of the system - if relevant
22 patient.identifier.type.coding.code code Symbol in syntax defined by the system
23 patient.identifier.type.coding.display string Representation defined by the system
24 patient.identifier.type.coding.userSelected boolean If this coding was chosen directly by the user
25 patient.identifier.type.text string Plain text representation of the concept
26 patient.identifier.system uri The namespace for the identifier value
27 patient.identifier.value string The value that is unique
patient.identifier.period Period Time period when id is/was valid for use
28 patient.identifier.period.start dateTime Starting time with inclusive boundary
29 patient.identifier.period.end dateTime End time with inclusive boundary, if not ongoing
30 patient.display string Text alternative for the resource
31 created dateTime Response creation date
insurer Reference Party responsible for reimbursement
32 insurer.reference string Literal reference, Relative, internal or absolute URL
33 insurer.type uri Type the reference refers to (e.g. "Patient")
insurer.identifier Identifier Logical reference, when literal reference is not known
34 insurer.identifier.use code usual | official | temp | secondary | old (If known)
insurer.identifier.type CodeableConcept Description of identifier
insurer.identifier.type.coding Coding Code defined by a terminology system
35 insurer.identifier.type.coding.system uri Identity of the terminology system
36 insurer.identifier.type.coding.version string Version of the system - if relevant
37 insurer.identifier.type.coding.code code Symbol in syntax defined by the system
38 insurer.identifier.type.coding.display string Representation defined by the system
39 insurer.identifier.type.coding.userSelected boolean If this coding was chosen directly by the user
40 insurer.identifier.type.text string Plain text representation of the concept
41 insurer.identifier.system uri The namespace for the identifier value
42 insurer.identifier.value string The value that is unique
insurer.identifier.period Period Time period when id is/was valid for use
43 insurer.identifier.period.start dateTime Starting time with inclusive boundary
44 insurer.identifier.period.end dateTime End time with inclusive boundary, if not ongoing
45 insurer.display string Text alternative for the resource
requestor Reference Party responsible for the claim
46 requestor.reference string Literal reference, Relative, internal or absolute URL
47 requestor.type uri Type the reference refers to (e.g. "Patient")
requestor.identifier Identifier Logical reference, when literal reference is not known
48 requestor.identifier.use code usual | official | temp | secondary | old (If known)
requestor.identifier.type CodeableConcept Description of identifier
requestor.identifier.type.coding Coding Code defined by a terminology system
49 requestor.identifier.type.coding.system uri Identity of the terminology system
50 requestor.identifier.type.coding.version string Version of the system - if relevant
51 requestor.identifier.type.coding.code code Symbol in syntax defined by the system
52 requestor.identifier.type.coding.display string Representation defined by the system
53 requestor.identifier.type.coding.userSelected boolean If this coding was chosen directly by the user
54 requestor.identifier.type.text string Plain text representation of the concept
55 requestor.identifier.system uri The namespace for the identifier value
56 requestor.identifier.value string The value that is unique
requestor.identifier.period Period Time period when id is/was valid for use
57 requestor.identifier.period.start dateTime Starting time with inclusive boundary
58 requestor.identifier.period.end dateTime End time with inclusive boundary, if not ongoing
59 requestor.display string Text alternative for the resource
request Reference Id of resource triggering adjudication
60 request.reference string Literal reference, Relative, internal or absolute URL
61 request.type uri Type the reference refers to (e.g. "Patient")
request.identifier Identifier Logical reference, when literal reference is not known
62 request.identifier.use code usual | official | temp | secondary | old (If known)
request.identifier.type CodeableConcept Description of identifier
request.identifier.type.coding Coding Code defined by a terminology system
63 request.identifier.type.coding.system uri Identity of the terminology system
64 request.identifier.type.coding.version string Version of the system - if relevant
65 request.identifier.type.coding.code code Symbol in syntax defined by the system
66 request.identifier.type.coding.display string Representation defined by the system
67 request.identifier.type.coding.userSelected boolean If this coding was chosen directly by the user
68 request.identifier.type.text string Plain text representation of the concept
69 request.identifier.system uri The namespace for the identifier value
70 request.identifier.value string The value that is unique
request.identifier.period Period Time period when id is/was valid for use
71 request.identifier.period.start dateTime Starting time with inclusive boundary
72 request.identifier.period.end dateTime End time with inclusive boundary, if not ongoing
73 request.display string Text alternative for the resource
74 outcome code queued | complete | error | partial
75 disposition string Disposition Message
76 preAuthRef string Preauthorization reference
preAuthPeriod Period Preauthorization reference effective period
77 preAuthPeriod.start dateTime Starting time with inclusive boundary
78 preAuthPeriod.end dateTime End time with inclusive boundary, if not ongoing
payeeType CodeableConcept Party to be paid any benefits payable
payeeType.coding Coding Code defined by a terminology system
79 payeeType.coding.system uri Identity of the terminology system
80 payeeType.coding.version string Version of the system - if relevant
81 payeeType.coding.code code Symbol in syntax defined by the system
82 payeeType.coding.display string Representation defined by the system
83 payeeType.coding.userSelected boolean If this coding was chosen directly by the user
84 payeeType.text string Plain text representation of the concept
payment Payment Details
payment.type CodeableConcept Partial or complete payment
payment.type.coding Coding Code defined by a terminology system
85 payment.type.coding.system uri Identity of the terminology system
86 payment.type.coding.version string Version of the system - if relevant
87 payment.type.coding.code code Symbol in syntax defined by the system
88 payment.type.coding.display string Representation defined by the system
89 payment.type.coding.userSelected boolean If this coding was chosen directly by the user
90 payment.type.text string Plain text representation of the concept
payment.adjustment Money Payment adjustment for non-claim issues
91 payment.adjustment.value decimal Numerical value (with implicit precision)
92 payment.adjustment.currency code ISO 4217 Currency Code
payment.adjustmentReason CodeableConcept Explanation for the adjustment
payment.adjustmentReason.coding Coding Code defined by a terminology system
93 payment.adjustmentReason.coding.system uri Identity of the terminology system
94 payment.adjustmentReason.coding.version string Version of the system - if relevant
95 payment.adjustmentReason.coding.code code Symbol in syntax defined by the system
96 payment.adjustmentReason.coding.display string Representation defined by the system
97 payment.adjustmentReason.coding.userSelected boolean If this coding was chosen directly by the user
98 payment.adjustmentReason.text string Plain text representation of the concept
99 payment.date date Expected date of payment
payment.amount Money Payable amount after adjustment
100 payment.amount.value decimal Numerical value (with implicit precision)
101 payment.amount.currency code ISO 4217 Currency Code
payment.identifier Identifier Business identifier for the payment
102 payment.identifier.use code usual | official | temp | secondary | old (If known)
payment.identifier.type CodeableConcept Description of identifier
payment.identifier.type.coding Coding Code defined by a terminology system
103 payment.identifier.type.coding.system uri Identity of the terminology system
104 payment.identifier.type.coding.version string Version of the system - if relevant
105 payment.identifier.type.coding.code code Symbol in syntax defined by the system
106 payment.identifier.type.coding.display string Representation defined by the system
107 payment.identifier.type.coding.userSelected boolean If this coding was chosen directly by the user
108 payment.identifier.type.text string Plain text representation of the concept
109 payment.identifier.system uri The namespace for the identifier value
110 payment.identifier.value string The value that is unique
payment.identifier.period Period Time period when id is/was valid for use
111 payment.identifier.period.start dateTime Starting time with inclusive boundary
112 payment.identifier.period.end dateTime End time with inclusive boundary, if not ongoing
fundsReserve CodeableConcept Funds reserved status
fundsReserve.coding Coding Code defined by a terminology system
113 fundsReserve.coding.system uri Identity of the terminology system
114 fundsReserve.coding.version string Version of the system - if relevant
115 fundsReserve.coding.code code Symbol in syntax defined by the system
116 fundsReserve.coding.display string Representation defined by the system
117 fundsReserve.coding.userSelected boolean If this coding was chosen directly by the user
118 fundsReserve.text string Plain text representation of the concept
formCode CodeableConcept Printed form identifier
formCode.coding Coding Code defined by a terminology system
119 formCode.coding.system uri Identity of the terminology system
120 formCode.coding.version string Version of the system - if relevant
121 formCode.coding.code code Symbol in syntax defined by the system
122 formCode.coding.display string Representation defined by the system
123 formCode.coding.userSelected boolean If this coding was chosen directly by the user
124 formCode.text string Plain text representation of the concept
form Attachment Printed reference or actual form
125 form.contentType code Mime type of the content, with charset etc.
126 form.language code Human language of the content (BCP-47)
127 form.data base64Binary Data inline, base64ed
128 form.url url Uri where the data can be found
129 form.size unsignedInt Number of bytes of content (if url provided)
130 form.hash base64Binary Hash of the data (sha-1, base64ed)
131 form.title string Label to display in place of the data
132 form.creation dateTime Date attachment was first created
Row identifier
# path type required description
0 string * Subrow identifier. Must be string "identifier"
identifier Identifier Business Identifier for a claim response
1 identifier.use code usual | official | temp | secondary | old (If known)
identifier.type CodeableConcept Description of identifier
identifier.type.coding Coding Code defined by a terminology system
2 identifier.type.coding.system uri Identity of the terminology system
3 identifier.type.coding.version string Version of the system - if relevant
4 identifier.type.coding.code code Symbol in syntax defined by the system
5 identifier.type.coding.display string Representation defined by the system
6 identifier.type.coding.userSelected boolean If this coding was chosen directly by the user
7 identifier.type.text string Plain text representation of the concept
8 identifier.system uri The namespace for the identifier value
9 identifier.value string The value that is unique
identifier.period Period Time period when id is/was valid for use
10 identifier.period.start dateTime Starting time with inclusive boundary
11 identifier.period.end dateTime End time with inclusive boundary, if not ongoing
Row item
# path type required description
0 string * Subrow identifier. Must be string "item"
item Adjudication for claim line items
1 item.itemSequence positiveInt Claim item instance identifier
2 item.noteNumber positiveInt Applicable note numbers
item.adjudication Adjudication details
item.adjudication.category CodeableConcept Type of adjudication information
item.adjudication.category.coding Coding Code defined by a terminology system
3 item.adjudication.category.coding.system uri Identity of the terminology system
4 item.adjudication.category.coding.version string Version of the system - if relevant
5 item.adjudication.category.coding.code code Symbol in syntax defined by the system
6 item.adjudication.category.coding.display string Representation defined by the system
7 item.adjudication.category.coding.userSelected boolean If this coding was chosen directly by the user
8 item.adjudication.category.text string Plain text representation of the concept
item.adjudication.reason CodeableConcept Explanation of adjudication outcome
item.adjudication.reason.coding Coding Code defined by a terminology system
9 item.adjudication.reason.coding.system uri Identity of the terminology system
10 item.adjudication.reason.coding.version string Version of the system - if relevant
11 item.adjudication.reason.coding.code code Symbol in syntax defined by the system
12 item.adjudication.reason.coding.display string Representation defined by the system
13 item.adjudication.reason.coding.userSelected boolean If this coding was chosen directly by the user
14 item.adjudication.reason.text string Plain text representation of the concept
item.adjudication.amount Money Monetary amount
15 item.adjudication.amount.value decimal Numerical value (with implicit precision)
16 item.adjudication.amount.currency code ISO 4217 Currency Code
17 item.adjudication.value decimal Non-monetary value
item.detail Adjudication for claim details
18 item.detail.detailSequence positiveInt Claim detail instance identifier
19 item.detail.noteNumber positiveInt Applicable note numbers
item.detail.adjudication Detail level adjudication details
item.detail.adjudication.category CodeableConcept Type of adjudication information
item.detail.adjudication.category.coding Coding Code defined by a terminology system
20 item.detail.adjudication.category.coding.system uri Identity of the terminology system
21 item.detail.adjudication.category.coding.version string Version of the system - if relevant
22 item.detail.adjudication.category.coding.code code Symbol in syntax defined by the system
23 item.detail.adjudication.category.coding.display string Representation defined by the system
24 item.detail.adjudication.category.coding.userSelected boolean If this coding was chosen directly by the user
25 item.detail.adjudication.category.text string Plain text representation of the concept
item.detail.adjudication.reason CodeableConcept Explanation of adjudication outcome
item.detail.adjudication.reason.coding Coding Code defined by a terminology system
26 item.detail.adjudication.reason.coding.system uri Identity of the terminology system
27 item.detail.adjudication.reason.coding.version string Version of the system - if relevant
28 item.detail.adjudication.reason.coding.code code Symbol in syntax defined by the system
29 item.detail.adjudication.reason.coding.display string Representation defined by the system
30 item.detail.adjudication.reason.coding.userSelected boolean If this coding was chosen directly by the user
31 item.detail.adjudication.reason.text string Plain text representation of the concept
item.detail.adjudication.amount Money Monetary amount
32 item.detail.adjudication.amount.value decimal Numerical value (with implicit precision)
33 item.detail.adjudication.amount.currency code ISO 4217 Currency Code
34 item.detail.adjudication.value decimal Non-monetary value
item.detail.subDetail Adjudication for claim sub-details
35 item.detail.subDetail.subDetailSequence positiveInt Claim sub-detail instance identifier
36 item.detail.subDetail.noteNumber positiveInt Applicable note numbers
item.detail.subDetail.adjudication Subdetail level adjudication details
item.detail.subDetail.adjudication.category CodeableConcept Type of adjudication information
item.detail.subDetail.adjudication.category.coding Coding Code defined by a terminology system
37 item.detail.subDetail.adjudication.category.coding.system uri Identity of the terminology system
38 item.detail.subDetail.adjudication.category.coding.version string Version of the system - if relevant
39 item.detail.subDetail.adjudication.category.coding.code code Symbol in syntax defined by the system
40 item.detail.subDetail.adjudication.category.coding.display string Representation defined by the system
41 item.detail.subDetail.adjudication.category.coding.userSelected boolean If this coding was chosen directly by the user
42 item.detail.subDetail.adjudication.category.text string Plain text representation of the concept
item.detail.subDetail.adjudication.reason CodeableConcept Explanation of adjudication outcome
item.detail.subDetail.adjudication.reason.coding Coding Code defined by a terminology system
43 item.detail.subDetail.adjudication.reason.coding.system uri Identity of the terminology system
44 item.detail.subDetail.adjudication.reason.coding.version string Version of the system - if relevant
45 item.detail.subDetail.adjudication.reason.coding.code code Symbol in syntax defined by the system
46 item.detail.subDetail.adjudication.reason.coding.display string Representation defined by the system
47 item.detail.subDetail.adjudication.reason.coding.userSelected boolean If this coding was chosen directly by the user
48 item.detail.subDetail.adjudication.reason.text string Plain text representation of the concept
item.detail.subDetail.adjudication.amount Money Monetary amount
49 item.detail.subDetail.adjudication.amount.value decimal Numerical value (with implicit precision)
50 item.detail.subDetail.adjudication.amount.currency code ISO 4217 Currency Code
51 item.detail.subDetail.adjudication.value decimal Non-monetary value
Row addItem
# path type required description
0 string * Subrow identifier. Must be string "addItem"
addItem Insurer added line items
1 addItem.itemSequence positiveInt Item sequence number
2 addItem.detailSequence positiveInt Detail sequence number
3 addItem.subdetailSequence positiveInt Subdetail sequence number
addItem.provider Reference Authorized providers
4 addItem.provider.reference string Literal reference, Relative, internal or absolute URL
5 addItem.provider.type uri Type the reference refers to (e.g. "Patient")
addItem.provider.identifier Identifier Logical reference, when literal reference is not known
6 addItem.provider.identifier.use code usual | official | temp | secondary | old (If known)
addItem.provider.identifier.type CodeableConcept Description of identifier
addItem.provider.identifier.type.coding Coding Code defined by a terminology system
7 addItem.provider.identifier.type.coding.system uri Identity of the terminology system
8 addItem.provider.identifier.type.coding.version string Version of the system - if relevant
9 addItem.provider.identifier.type.coding.code code Symbol in syntax defined by the system
10 addItem.provider.identifier.type.coding.display string Representation defined by the system
11 addItem.provider.identifier.type.coding.userSelected boolean If this coding was chosen directly by the user
12 addItem.provider.identifier.type.text string Plain text representation of the concept
13 addItem.provider.identifier.system uri The namespace for the identifier value
14 addItem.provider.identifier.value string The value that is unique
addItem.provider.identifier.period Period Time period when id is/was valid for use
15 addItem.provider.identifier.period.start dateTime Starting time with inclusive boundary
16 addItem.provider.identifier.period.end dateTime End time with inclusive boundary, if not ongoing
17 addItem.provider.display string Text alternative for the resource
addItem.productOrService CodeableConcept Billing, service, product, or drug code
addItem.productOrService.coding Coding Code defined by a terminology system
18 addItem.productOrService.coding.system uri Identity of the terminology system
19 addItem.productOrService.coding.version string Version of the system - if relevant
20 addItem.productOrService.coding.code code Symbol in syntax defined by the system
21 addItem.productOrService.coding.display string Representation defined by the system
22 addItem.productOrService.coding.userSelected boolean If this coding was chosen directly by the user
23 addItem.productOrService.text string Plain text representation of the concept
addItem.modifier CodeableConcept Service/Product billing modifiers
addItem.modifier.coding Coding Code defined by a terminology system
24 addItem.modifier.coding.system uri Identity of the terminology system
25 addItem.modifier.coding.version string Version of the system - if relevant
26 addItem.modifier.coding.code code Symbol in syntax defined by the system
27 addItem.modifier.coding.display string Representation defined by the system
28 addItem.modifier.coding.userSelected boolean If this coding was chosen directly by the user
29 addItem.modifier.text string Plain text representation of the concept
addItem.programCode CodeableConcept Program the product or service is provided under
addItem.programCode.coding Coding Code defined by a terminology system
30 addItem.programCode.coding.system uri Identity of the terminology system
31 addItem.programCode.coding.version string Version of the system - if relevant
32 addItem.programCode.coding.code code Symbol in syntax defined by the system
33 addItem.programCode.coding.display string Representation defined by the system
34 addItem.programCode.coding.userSelected boolean If this coding was chosen directly by the user
35 addItem.programCode.text string Plain text representation of the concept
addItem.serviced[x] Date or dates of service or product delivery
36 addItem.servicedDate date
addItem.servicedPeriod Period
37 addItem.servicedPeriod.start dateTime Starting time with inclusive boundary
38 addItem.servicedPeriod.end dateTime End time with inclusive boundary, if not ongoing
addItem.location[x] Place of service or where product was supplied
addItem.locationCodeableConcept CodeableConcept
addItem.locationCodeableConcept.coding Coding Code defined by a terminology system
39 addItem.locationCodeableConcept.coding.system uri Identity of the terminology system
40 addItem.locationCodeableConcept.coding.version string Version of the system - if relevant
41 addItem.locationCodeableConcept.coding.code code Symbol in syntax defined by the system
42 addItem.locationCodeableConcept.coding.display string Representation defined by the system
43 addItem.locationCodeableConcept.coding.userSelected boolean If this coding was chosen directly by the user
44 addItem.locationCodeableConcept.text string Plain text representation of the concept
addItem.locationAddress Address
45 addItem.locationAddress.use code home | work | temp | old | billing - purpose of this address
46 addItem.locationAddress.type code postal | physical | both
47 addItem.locationAddress.text string Text representation of the address
48 addItem.locationAddress.line string Street name, number, direction & P.O. Box etc.
49 addItem.locationAddress.city string Name of city, town etc.
50 addItem.locationAddress.district string District name (aka county)
51 addItem.locationAddress.state string Sub-unit of country (abbreviations ok)
52 addItem.locationAddress.postalCode string Postal code for area
53 addItem.locationAddress.country string Country (e.g. can be ISO 3166 2 or 3 letter code)
addItem.locationAddress.period Period Time period when address was/is in use
54 addItem.locationAddress.period.start dateTime Starting time with inclusive boundary
55 addItem.locationAddress.period.end dateTime End time with inclusive boundary, if not ongoing
addItem.locationReference Reference
56 addItem.locationReference.reference string Literal reference, Relative, internal or absolute URL
57 addItem.locationReference.type uri Type the reference refers to (e.g. "Patient")
addItem.locationReference.identifier Identifier Logical reference, when literal reference is not known
58 addItem.locationReference.identifier.use code usual | official | temp | secondary | old (If known)
addItem.locationReference.identifier.type CodeableConcept Description of identifier
addItem.locationReference.identifier.type.coding Coding Code defined by a terminology system
59 addItem.locationReference.identifier.type.coding.system uri Identity of the terminology system
60 addItem.locationReference.identifier.type.coding.version string Version of the system - if relevant
61 addItem.locationReference.identifier.type.coding.code code Symbol in syntax defined by the system
62 addItem.locationReference.identifier.type.coding.display string Representation defined by the system
63 addItem.locationReference.identifier.type.coding.userSelected boolean If this coding was chosen directly by the user
64 addItem.locationReference.identifier.type.text string Plain text representation of the concept
65 addItem.locationReference.identifier.system uri The namespace for the identifier value
66 addItem.locationReference.identifier.value string The value that is unique
addItem.locationReference.identifier.period Period Time period when id is/was valid for use
67 addItem.locationReference.identifier.period.start dateTime Starting time with inclusive boundary
68 addItem.locationReference.identifier.period.end dateTime End time with inclusive boundary, if not ongoing
69 addItem.locationReference.display string Text alternative for the resource
addItem.quantity Quantity Count of products or services
70 addItem.quantity.value decimal Numerical value (with implicit precision)
71 addItem.quantity.unit string Unit representation
72 addItem.quantity.system uri System that defines coded unit form
73 addItem.quantity.code code Coded form of the unit
addItem.unitPrice Money Fee, charge or cost per item
74 addItem.unitPrice.value decimal Numerical value (with implicit precision)
75 addItem.unitPrice.currency code ISO 4217 Currency Code
76 addItem.factor decimal Price scaling factor
addItem.net Money Total item cost
77 addItem.net.value decimal Numerical value (with implicit precision)
78 addItem.net.currency code ISO 4217 Currency Code
addItem.bodySite CodeableConcept Anatomical location
addItem.bodySite.coding Coding Code defined by a terminology system
79 addItem.bodySite.coding.system uri Identity of the terminology system
80 addItem.bodySite.coding.version string Version of the system - if relevant
81 addItem.bodySite.coding.code code Symbol in syntax defined by the system
82 addItem.bodySite.coding.display string Representation defined by the system
83 addItem.bodySite.coding.userSelected boolean If this coding was chosen directly by the user
84 addItem.bodySite.text string Plain text representation of the concept
addItem.subSite CodeableConcept Anatomical sub-location
addItem.subSite.coding Coding Code defined by a terminology system
85 addItem.subSite.coding.system uri Identity of the terminology system
86 addItem.subSite.coding.version string Version of the system - if relevant
87 addItem.subSite.coding.code code Symbol in syntax defined by the system
88 addItem.subSite.coding.display string Representation defined by the system
89 addItem.subSite.coding.userSelected boolean If this coding was chosen directly by the user
90 addItem.subSite.text string Plain text representation of the concept
91 addItem.noteNumber positiveInt Applicable note numbers
addItem.adjudication Added items adjudication
addItem.adjudication.category CodeableConcept Type of adjudication information
addItem.adjudication.category.coding Coding Code defined by a terminology system
92 addItem.adjudication.category.coding.system uri Identity of the terminology system
93 addItem.adjudication.category.coding.version string Version of the system - if relevant
94 addItem.adjudication.category.coding.code code Symbol in syntax defined by the system
95 addItem.adjudication.category.coding.display string Representation defined by the system
96 addItem.adjudication.category.coding.userSelected boolean If this coding was chosen directly by the user
97 addItem.adjudication.category.text string Plain text representation of the concept
addItem.adjudication.reason CodeableConcept Explanation of adjudication outcome
addItem.adjudication.reason.coding Coding Code defined by a terminology system
98 addItem.adjudication.reason.coding.system uri Identity of the terminology system
99 addItem.adjudication.reason.coding.version string Version of the system - if relevant
100 addItem.adjudication.reason.coding.code code Symbol in syntax defined by the system
101 addItem.adjudication.reason.coding.display string Representation defined by the system
102 addItem.adjudication.reason.coding.userSelected boolean If this coding was chosen directly by the user
103 addItem.adjudication.reason.text string Plain text representation of the concept
addItem.adjudication.amount Money Monetary amount
104 addItem.adjudication.amount.value decimal Numerical value (with implicit precision)
105 addItem.adjudication.amount.currency code ISO 4217 Currency Code
106 addItem.adjudication.value decimal Non-monetary value
addItem.detail Insurer added line details
addItem.detail.productOrService CodeableConcept Billing, service, product, or drug code
addItem.detail.productOrService.coding Coding Code defined by a terminology system
107 addItem.detail.productOrService.coding.system uri Identity of the terminology system
108 addItem.detail.productOrService.coding.version string Version of the system - if relevant
109 addItem.detail.productOrService.coding.code code Symbol in syntax defined by the system
110 addItem.detail.productOrService.coding.display string Representation defined by the system
111 addItem.detail.productOrService.coding.userSelected boolean If this coding was chosen directly by the user
112 addItem.detail.productOrService.text string Plain text representation of the concept
addItem.detail.modifier CodeableConcept Service/Product billing modifiers
addItem.detail.modifier.coding Coding Code defined by a terminology system
113 addItem.detail.modifier.coding.system uri Identity of the terminology system
114 addItem.detail.modifier.coding.version string Version of the system - if relevant
115 addItem.detail.modifier.coding.code code Symbol in syntax defined by the system
116 addItem.detail.modifier.coding.display string Representation defined by the system
117 addItem.detail.modifier.coding.userSelected boolean If this coding was chosen directly by the user
118 addItem.detail.modifier.text string Plain text representation of the concept
addItem.detail.quantity Quantity Count of products or services
119 addItem.detail.quantity.value decimal Numerical value (with implicit precision)
120 addItem.detail.quantity.unit string Unit representation
121 addItem.detail.quantity.system uri System that defines coded unit form
122 addItem.detail.quantity.code code Coded form of the unit
addItem.detail.unitPrice Money Fee, charge or cost per item
123 addItem.detail.unitPrice.value decimal Numerical value (with implicit precision)
124 addItem.detail.unitPrice.currency code ISO 4217 Currency Code
125 addItem.detail.factor decimal Price scaling factor
addItem.detail.net Money Total item cost
126 addItem.detail.net.value decimal Numerical value (with implicit precision)
127 addItem.detail.net.currency code ISO 4217 Currency Code
128 addItem.detail.noteNumber positiveInt Applicable note numbers
addItem.detail.adjudication Added items detail adjudication
addItem.detail.adjudication.category CodeableConcept Type of adjudication information
addItem.detail.adjudication.category.coding Coding Code defined by a terminology system
129 addItem.detail.adjudication.category.coding.system uri Identity of the terminology system
130 addItem.detail.adjudication.category.coding.version string Version of the system - if relevant
131 addItem.detail.adjudication.category.coding.code code Symbol in syntax defined by the system
132 addItem.detail.adjudication.category.coding.display string Representation defined by the system
133 addItem.detail.adjudication.category.coding.userSelected boolean If this coding was chosen directly by the user
134 addItem.detail.adjudication.category.text string Plain text representation of the concept
addItem.detail.adjudication.reason CodeableConcept Explanation of adjudication outcome
addItem.detail.adjudication.reason.coding Coding Code defined by a terminology system
135 addItem.detail.adjudication.reason.coding.system uri Identity of the terminology system
136 addItem.detail.adjudication.reason.coding.version string Version of the system - if relevant
137 addItem.detail.adjudication.reason.coding.code code Symbol in syntax defined by the system
138 addItem.detail.adjudication.reason.coding.display string Representation defined by the system
139 addItem.detail.adjudication.reason.coding.userSelected boolean If this coding was chosen directly by the user
140 addItem.detail.adjudication.reason.text string Plain text representation of the concept
addItem.detail.adjudication.amount Money Monetary amount
141 addItem.detail.adjudication.amount.value decimal Numerical value (with implicit precision)
142 addItem.detail.adjudication.amount.currency code ISO 4217 Currency Code
143 addItem.detail.adjudication.value decimal Non-monetary value
addItem.detail.subDetail Insurer added line items
addItem.detail.subDetail.productOrService CodeableConcept Billing, service, product, or drug code
addItem.detail.subDetail.productOrService.coding Coding Code defined by a terminology system
144 addItem.detail.subDetail.productOrService.coding.system uri Identity of the terminology system
145 addItem.detail.subDetail.productOrService.coding.version string Version of the system - if relevant
146 addItem.detail.subDetail.productOrService.coding.code code Symbol in syntax defined by the system
147 addItem.detail.subDetail.productOrService.coding.display string Representation defined by the system
148 addItem.detail.subDetail.productOrService.coding.userSelected boolean If this coding was chosen directly by the user
149 addItem.detail.subDetail.productOrService.text string Plain text representation of the concept
addItem.detail.subDetail.modifier CodeableConcept Service/Product billing modifiers
addItem.detail.subDetail.modifier.coding Coding Code defined by a terminology system
150 addItem.detail.subDetail.modifier.coding.system uri Identity of the terminology system
151 addItem.detail.subDetail.modifier.coding.version string Version of the system - if relevant
152 addItem.detail.subDetail.modifier.coding.code code Symbol in syntax defined by the system
153 addItem.detail.subDetail.modifier.coding.display string Representation defined by the system
154 addItem.detail.subDetail.modifier.coding.userSelected boolean If this coding was chosen directly by the user
155 addItem.detail.subDetail.modifier.text string Plain text representation of the concept
addItem.detail.subDetail.quantity Quantity Count of products or services
156 addItem.detail.subDetail.quantity.value decimal Numerical value (with implicit precision)
157 addItem.detail.subDetail.quantity.unit string Unit representation
158 addItem.detail.subDetail.quantity.system uri System that defines coded unit form
159 addItem.detail.subDetail.quantity.code code Coded form of the unit
addItem.detail.subDetail.unitPrice Money Fee, charge or cost per item
160 addItem.detail.subDetail.unitPrice.value decimal Numerical value (with implicit precision)
161 addItem.detail.subDetail.unitPrice.currency code ISO 4217 Currency Code
162 addItem.detail.subDetail.factor decimal Price scaling factor
addItem.detail.subDetail.net Money Total item cost
163 addItem.detail.subDetail.net.value decimal Numerical value (with implicit precision)
164 addItem.detail.subDetail.net.currency code ISO 4217 Currency Code
165 addItem.detail.subDetail.noteNumber positiveInt Applicable note numbers
addItem.detail.subDetail.adjudication Added items detail adjudication
addItem.detail.subDetail.adjudication.category CodeableConcept Type of adjudication information
addItem.detail.subDetail.adjudication.category.coding Coding Code defined by a terminology system
166 addItem.detail.subDetail.adjudication.category.coding.system uri Identity of the terminology system
167 addItem.detail.subDetail.adjudication.category.coding.version string Version of the system - if relevant
168 addItem.detail.subDetail.adjudication.category.coding.code code Symbol in syntax defined by the system
169 addItem.detail.subDetail.adjudication.category.coding.display string Representation defined by the system
170 addItem.detail.subDetail.adjudication.category.coding.userSelected boolean If this coding was chosen directly by the user
171 addItem.detail.subDetail.adjudication.category.text string Plain text representation of the concept
addItem.detail.subDetail.adjudication.reason CodeableConcept Explanation of adjudication outcome
addItem.detail.subDetail.adjudication.reason.coding Coding Code defined by a terminology system
172 addItem.detail.subDetail.adjudication.reason.coding.system uri Identity of the terminology system
173 addItem.detail.subDetail.adjudication.reason.coding.version string Version of the system - if relevant
174 addItem.detail.subDetail.adjudication.reason.coding.code code Symbol in syntax defined by the system
175 addItem.detail.subDetail.adjudication.reason.coding.display string Representation defined by the system
176 addItem.detail.subDetail.adjudication.reason.coding.userSelected boolean If this coding was chosen directly by the user
177 addItem.detail.subDetail.adjudication.reason.text string Plain text representation of the concept
addItem.detail.subDetail.adjudication.amount Money Monetary amount
178 addItem.detail.subDetail.adjudication.amount.value decimal Numerical value (with implicit precision)
179 addItem.detail.subDetail.adjudication.amount.currency code ISO 4217 Currency Code
180 addItem.detail.subDetail.adjudication.value decimal Non-monetary value
Row adjudication
# path type required description
0 string * Subrow identifier. Must be string "adjudication"
adjudication Header-level adjudication
adjudication.category CodeableConcept Type of adjudication information
adjudication.category.coding Coding Code defined by a terminology system
1 adjudication.category.coding.system uri Identity of the terminology system
2 adjudication.category.coding.version string Version of the system - if relevant
3 adjudication.category.coding.code code Symbol in syntax defined by the system
4 adjudication.category.coding.display string Representation defined by the system
5 adjudication.category.coding.userSelected boolean If this coding was chosen directly by the user
6 adjudication.category.text string Plain text representation of the concept
adjudication.reason CodeableConcept Explanation of adjudication outcome
adjudication.reason.coding Coding Code defined by a terminology system
7 adjudication.reason.coding.system uri Identity of the terminology system
8 adjudication.reason.coding.version string Version of the system - if relevant
9 adjudication.reason.coding.code code Symbol in syntax defined by the system
10 adjudication.reason.coding.display string Representation defined by the system
11 adjudication.reason.coding.userSelected boolean If this coding was chosen directly by the user
12 adjudication.reason.text string Plain text representation of the concept
adjudication.amount Money Monetary amount
13 adjudication.amount.value decimal Numerical value (with implicit precision)
14 adjudication.amount.currency code ISO 4217 Currency Code
15 adjudication.value decimal Non-monetary value
Row total
# path type required description
0 string * Subrow identifier. Must be string "total"
total Adjudication totals
total.category CodeableConcept Type of adjudication information
total.category.coding Coding Code defined by a terminology system
1 total.category.coding.system uri Identity of the terminology system
2 total.category.coding.version string Version of the system - if relevant
3 total.category.coding.code code Symbol in syntax defined by the system
4 total.category.coding.display string Representation defined by the system
5 total.category.coding.userSelected boolean If this coding was chosen directly by the user
6 total.category.text string Plain text representation of the concept
total.amount Money Financial total for the category
7 total.amount.value decimal Numerical value (with implicit precision)
8 total.amount.currency code ISO 4217 Currency Code
Row processNote
# path type required description
0 string * Subrow identifier. Must be string "processNote"
processNote Note concerning adjudication
1 processNote.number positiveInt Note instance identifier
2 processNote.type code display | print | printoper
3 processNote.text string Note explanatory text
processNote.language CodeableConcept Language of the text
processNote.language.coding Coding Code defined by a terminology system
4 processNote.language.coding.system uri Identity of the terminology system
5 processNote.language.coding.version string Version of the system - if relevant
6 processNote.language.coding.code code Symbol in syntax defined by the system
7 processNote.language.coding.display string Representation defined by the system
8 processNote.language.coding.userSelected boolean If this coding was chosen directly by the user
9 processNote.language.text string Plain text representation of the concept
Row communicationRequest
# path type required description
0 string * Subrow identifier. Must be string "communicationRequest"
communicationRequest Reference Request for additional information
1 communicationRequest.reference string Literal reference, Relative, internal or absolute URL
2 communicationRequest.type uri Type the reference refers to (e.g. "Patient")
communicationRequest.identifier Identifier Logical reference, when literal reference is not known
3 communicationRequest.identifier.use code usual | official | temp | secondary | old (If known)
communicationRequest.identifier.type CodeableConcept Description of identifier
communicationRequest.identifier.type.coding Coding Code defined by a terminology system
4 communicationRequest.identifier.type.coding.system uri Identity of the terminology system
5 communicationRequest.identifier.type.coding.version string Version of the system - if relevant
6 communicationRequest.identifier.type.coding.code code Symbol in syntax defined by the system
7 communicationRequest.identifier.type.coding.display string Representation defined by the system
8 communicationRequest.identifier.type.coding.userSelected boolean If this coding was chosen directly by the user
9 communicationRequest.identifier.type.text string Plain text representation of the concept
10 communicationRequest.identifier.system uri The namespace for the identifier value
11 communicationRequest.identifier.value string The value that is unique
communicationRequest.identifier.period Period Time period when id is/was valid for use
12 communicationRequest.identifier.period.start dateTime Starting time with inclusive boundary
13 communicationRequest.identifier.period.end dateTime End time with inclusive boundary, if not ongoing
14 communicationRequest.display string Text alternative for the resource
Row insurance
# path type required description
0 string * Subrow identifier. Must be string "insurance"
insurance Patient insurance information
1 insurance.sequence positiveInt Insurance instance identifier
2 insurance.focal boolean Coverage to be used for adjudication
insurance.coverage Reference Insurance information
3 insurance.coverage.reference string Literal reference, Relative, internal or absolute URL
4 insurance.coverage.type uri Type the reference refers to (e.g. "Patient")
insurance.coverage.identifier Identifier Logical reference, when literal reference is not known
5 insurance.coverage.identifier.use code usual | official | temp | secondary | old (If known)
insurance.coverage.identifier.type CodeableConcept Description of identifier
insurance.coverage.identifier.type.coding Coding Code defined by a terminology system
6 insurance.coverage.identifier.type.coding.system uri Identity of the terminology system
7 insurance.coverage.identifier.type.coding.version string Version of the system - if relevant
8 insurance.coverage.identifier.type.coding.code code Symbol in syntax defined by the system
9 insurance.coverage.identifier.type.coding.display string Representation defined by the system
10 insurance.coverage.identifier.type.coding.userSelected boolean If this coding was chosen directly by the user
11 insurance.coverage.identifier.type.text string Plain text representation of the concept
12 insurance.coverage.identifier.system uri The namespace for the identifier value
13 insurance.coverage.identifier.value string The value that is unique
insurance.coverage.identifier.period Period Time period when id is/was valid for use
14 insurance.coverage.identifier.period.start dateTime Starting time with inclusive boundary
15 insurance.coverage.identifier.period.end dateTime End time with inclusive boundary, if not ongoing
16 insurance.coverage.display string Text alternative for the resource
17 insurance.businessArrangement string Additional provider contract number
insurance.claimResponse Reference Adjudication results
18 insurance.claimResponse.reference string Literal reference, Relative, internal or absolute URL
19 insurance.claimResponse.type uri Type the reference refers to (e.g. "Patient")
insurance.claimResponse.identifier Identifier Logical reference, when literal reference is not known
20 insurance.claimResponse.identifier.use code usual | official | temp | secondary | old (If known)
insurance.claimResponse.identifier.type CodeableConcept Description of identifier
insurance.claimResponse.identifier.type.coding Coding Code defined by a terminology system
21 insurance.claimResponse.identifier.type.coding.system uri Identity of the terminology system
22 insurance.claimResponse.identifier.type.coding.version string Version of the system - if relevant
23 insurance.claimResponse.identifier.type.coding.code code Symbol in syntax defined by the system
24 insurance.claimResponse.identifier.type.coding.display string Representation defined by the system
25 insurance.claimResponse.identifier.type.coding.userSelected boolean If this coding was chosen directly by the user
26 insurance.claimResponse.identifier.type.text string Plain text representation of the concept
27 insurance.claimResponse.identifier.system uri The namespace for the identifier value
28 insurance.claimResponse.identifier.value string The value that is unique
insurance.claimResponse.identifier.period Period Time period when id is/was valid for use
29 insurance.claimResponse.identifier.period.start dateTime Starting time with inclusive boundary
30 insurance.claimResponse.identifier.period.end dateTime End time with inclusive boundary, if not ongoing
31 insurance.claimResponse.display string Text alternative for the resource
Row error
# path type required description
0 string * Subrow identifier. Must be string "error"
error Processing errors
1 error.itemSequence positiveInt Item sequence number
2 error.detailSequence positiveInt Detail sequence number
3 error.subDetailSequence positiveInt Subdetail sequence number
error.code CodeableConcept Error code detailing processing issues
error.code.coding Coding Code defined by a terminology system
4 error.code.coding.system uri Identity of the terminology system
5 error.code.coding.version string Version of the system - if relevant
6 error.code.coding.code code Symbol in syntax defined by the system
7 error.code.coding.display string Representation defined by the system
8 error.code.coding.userSelected boolean If this coding was chosen directly by the user
9 error.code.text string Plain text representation of the concept

Examples

Example #1
Input CSV
ClaimResponse,4,"R3501","active","http://terminology.hl7.org/CodeSystem/claim-type",,"oral",,,,,,,,,,"claim","Patient/1",,,,,,,,,,,,,,"2014-08-16",,,,,,,,,,"http://www.jurisdiction.org/insurers","555123",,,,"Practitioner/1",,,,,,,,,,,,,,"Claim/100156",,,,,,,,,,,,,,"error","Claim could not be processed",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,"http://terminology.hl7.org/CodeSystem/forms-codes",,"2",,,,,,,,,,,
identifier,,,,,,,,"http://www.BenefitsInc.com/fhir/remittance","R3501",,
processNote,1,"display","Invalid claim","urn:ietf:bcp:47",,"en-CA",,,
communicationRequest,"CommunicationRequest/fm-solicit",,,,,,,,,,,,,
error,3,2,,"http://terminology.hl7.org/CodeSystem/adjudication-error",,"a002",,,
Resulting resource
{
  "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"
          }
        ]
      }
    }
  ]
}
Example #2
Input CSV
ClaimResponse,10,"R3503","active","http://terminology.hl7.org/CodeSystem/claim-type",,"oral",,,,,,,,,,"claim","Patient/1",,,,,,,,,,,,,,"2014-08-16",,,,,,,,,,"http://www.jurisdiction.org/insurers","555123",,,,"Organization/1",,,,,,,,,,,,,,,,,,,,,,,"http://happyvalley.com/claim","12346",,,,"complete","Claim settled as per contract.",,,,"http://terminology.hl7.org/CodeSystem/payeetype",,"provider",,,,"http://terminology.hl7.org/CodeSystem/ex-paymenttype",,"complete",,,,,,,,,,,,"2014-08-31",100.47,"USD",,,,,,,,"http://www.BenefitsInc.com/fhir/paymentidentifier","201408-2-15507",,,,,,,,,,,,,,,,,,,,,,
identifier,,,,,,,,"http://www.BenefitsInc.com/fhir/remittance","R3503",,
item,1,,,,"eligible",,,,,,,,,,0,"USD",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
item,2,,,,"eligible",,,,,,,,,,105,"USD",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
item,3,,,,"eligible",,,,,,,,,,750,"USD",,1,,,,"eligible",,,,,,,,,,750,"USD",,,,,,,,,,,,,,,,,,
addItem,1,,,,,,,,,,,,,,,,,"http://example.org/fhir/oralservicecodes",,"1101",,,,"http://example.org/fhir/modifiers",,"x","None",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,135.57,"USD",,,,,,,,,,,,,101,,,"eligible",,,,,,,,,,100,"USD",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
addItem,1,,,,,,,,,,,,,,,,,"http://example.org/fhir/oralservicecodes",,"2141","Radiograph, bytewing",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,35.57,"USD",,,,,,,,,,,,,,,,"eligible",,,,,,,,,,35.57,"USD",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
addItem,3,2,,,,,,,,,,,,,,,,"http://example.org/fhir/oralservicecodes",,"expense",,,,"http://example.org/fhir/modifiers",,"x","None",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,350,"USD",,,,,,,,,,,,,101,,,"eligible",,,,,,,,,,350,"USD",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
total,,,"submitted",,,,1340.57,"USD"
total,,,"benefit",,,,1054.47,"USD"
processNote,101,"print","Package codes are not permitted. Codes replaced by Insurer.","urn:ietf:bcp:47",,"en-CA",,,
Resulting resource
{
  "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,
            "currency": "USD"
          }
        },
        {
          "category": {
            "coding": [
              {
                "code": "benefit"
              }
            ]
          },
          "amount": {
            "value": 0,
            "currency": "USD"
          }
        }
      ]
    },
    {
      "itemSequence": 2,
      "adjudication": [
        {
          "category": {
            "coding": [
              {
                "code": "eligible"
              }
            ]
          },
          "amount": {
            "value": 105,
            "currency": "USD"
          }
        },
        {
          "category": {
            "coding": [
              {
                "code": "eligpercent"
              }
            ]
          },
          "value": 80
        },
        {
          "category": {
            "coding": [
              {
                "code": "benefit"
              }
            ]
          },
          "amount": {
            "value": 84,
            "currency": "USD"
          }
        }
      ]
    },
    {
      "itemSequence": 3,
      "adjudication": [
        {
          "category": {
            "coding": [
              {
                "code": "eligible"
              }
            ]
          },
          "amount": {
            "value": 750,
            "currency": "USD"
          }
        },
        {
          "category": {
            "coding": [
              {
                "code": "eligpercent"
              }
            ]
          },
          "value": 80
        },
        {
          "category": {
            "coding": [
              {
                "code": "benefit"
              }
            ]
          },
          "amount": {
            "value": 600,
            "currency": "USD"
          }
        }
      ],
      "detail": [
        {
          "detailSequence": 1,
          "adjudication": [
            {
              "category": {
                "coding": [
                  {
                    "code": "eligible"
                  }
                ]
              },
              "amount": {
                "value": 750,
                "currency": "USD"
              }
            },
            {
              "category": {
                "coding": [
                  {
                    "code": "eligpercent"
                  }
                ]
              },
              "value": 80
            },
            {
              "category": {
                "coding": [
                  {
                    "code": "benefit"
                  }
                ]
              },
              "amount": {
                "value": 600,
                "currency": "USD"
              }
            }
          ]
        },
        {
          "detailSequence": 2,
          "adjudication": [
            {
              "category": {
                "coding": [
                  {
                    "code": "eligible"
                  }
                ]
              },
              "amount": {
                "value": 0,
                "currency": "USD"
              }
            },
            {
              "category": {
                "coding": [
                  {
                    "code": "benefit"
                  }
                ]
              },
              "amount": {
                "value": 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,
            "currency": "USD"
          }
        },
        {
          "category": {
            "coding": [
              {
                "code": "copay"
              }
            ]
          },
          "amount": {
            "value": 10,
            "currency": "USD"
          }
        },
        {
          "category": {
            "coding": [
              {
                "code": "eligpercent"
              }
            ]
          },
          "value": 80
        },
        {
          "category": {
            "coding": [
              {
                "code": "benefit"
              }
            ]
          },
          "reason": {
            "coding": [
              {
                "system": "http://terminology.hl7.org/CodeSystem/adjudication-reason",
                "code": "ar002",
                "display": "Plan Limit Reached"
              }
            ]
          },
          "amount": {
            "value": 72,
            "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
        },
        {
          "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,
        "currency": "USD"
      },
      "noteNumber": [
        101
      ],
      "adjudication": [
        {
          "category": {
            "coding": [
              {
                "code": "eligible"
              }
            ]
          },
          "amount": {
            "value": 350,
            "currency": "USD"
          }
        },
        {
          "category": {
            "coding": [
              {
                "code": "eligpercent"
              }
            ]
          },
          "value": 80
        },
        {
          "category": {
            "coding": [
              {
                "code": "benefit"
              }
            ]
          },
          "amount": {
            "value": 270,
            "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"
          }
        ]
      }
    }
  ]
}
Example #3
Input CSV
ClaimResponse,4,"R3500","active","http://terminology.hl7.org/CodeSystem/claim-type",,"oral",,,,"http://terminology.hl7.org/CodeSystem/ex-claimsubtype",,"emergency",,,,"claim","Patient/1",,,,,,,,,,,,,,"2014-08-16",,,,,,,,,,"http://www.jurisdiction.org/insurers","555123",,,,"Organization/1",,,,,,,,,,,,,,"http://www.BenefitsInc.com/fhir/oralhealthclaim/15476332402",,,,,,,,,,,,,,"complete","Claim settled as per contract.",,,,"http://terminology.hl7.org/CodeSystem/payeetype",,"provider",,,,"http://terminology.hl7.org/CodeSystem/ex-paymenttype",,"complete",,,,,,,,,,,,"2014-08-31",100.47,"USD",,,,,,,,"http://www.BenefitsInc.com/fhir/paymentidentifier","201408-2-1569478",,,,,,,,,,,,,,,,,,,,,,
identifier,,,,,,,,"http://www.BenefitsInc.com/fhir/remittance","R3500",,
item,1,,,,"eligible",,,,,,,,,,135.57,"USD",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
total,,,"submitted",,,,135.57,"USD"
total,,,"benefit",,,,90.47,"USD"
Resulting resource
{
  "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/oralhealthclaim/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,
            "currency": "USD"
          }
        },
        {
          "category": {
            "coding": [
              {
                "code": "eligpercent"
              }
            ]
          },
          "value": 80
        },
        {
          "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"
    }
  }
}
Example #4
Input CSV
ClaimResponse,7,"UR3503","active","http://terminology.hl7.org/CodeSystem/claim-type",,"oral",,,,,,,,,,"preauthorization","Patient/1",,,,,,,,,,,,,,"2014-08-16",,,,,,,,,,"http://www.jurisdiction.org/insurers","444123",,,,"Organization/1",,,,,,,,,,,,,,,,,,,,,,,,,,,,"complete","The enclosed services are authorized for your provision within 30 days of this notice.","18SS12345",,,"http://terminology.hl7.org/CodeSystem/payeetype",,"provider",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
identifier,,,,,,,,"http://www.SocialBenefitsInc.com/fhir/ClaimResponse","UR3503",,
addItem,1,,,,,,,,,,,,,,,,,"http://example.org/fhir/oralservicecodes",,"1101",,,,"http://example.org/fhir/modifiers",,"x","None",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,250,"USD",,,,,,,,,,,,,101,,,"eligible",,,,,,,,,,250,"USD",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
addItem,1,,,,,,,,,,,,,,,,,"http://example.org/fhir/oralservicecodes",,"2101","Radiograph, series (12)",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,800,"USD",,,,,,,,,,,,,,,,"eligible",,,,,,,,,,800,"USD",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
total,,,"submitted",,,,1050,"USD"
total,,,"benefit",,,,1040,"USD"
processNote,101,"print","Please submit a Pre-Authorization request if a more extensive examination or urgent services are required.","urn:ietf:bcp:47",,"en-CA",,,
insurance,1,true,"Coverage/9876B1",,,,,,,,,,,,,,,,,,,,,,,,,,,,
Resulting resource
{
  "resourceType": "ClaimResponse",
  "id": "UR3503",
  "identifier": [
    {
      "system": "http://www.SocialBenefitsInc.com/fhir/ClaimResponse",
      "value": "UR3503"
    }
  ],
  "status": "active",
  "type": {
    "coding": [
      {
        "system": "http://terminology.hl7.org/CodeSystem/claim-type",
        "code": "oral"
      }
    ]
  },
  "use": "preauthorization",
  "patient": {
    "reference": "Patient/1"
  },
  "created": "2014-08-16",
  "insurer": {
    "identifier": {
      "system": "http://www.jurisdiction.org/insurers",
      "value": "444123"
    }
  },
  "requestor": {
    "reference": "Organization/1"
  },
  "outcome": "complete",
  "disposition": "The enclosed services are authorized for your provision within 30 days of this notice.",
  "preAuthRef": "18SS12345",
  "payeeType": {
    "coding": [
      {
        "system": "http://terminology.hl7.org/CodeSystem/payeetype",
        "code": "provider"
      }
    ]
  },
  "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": 250,
        "currency": "USD"
      },
      "noteNumber": [
        101
      ],
      "adjudication": [
        {
          "category": {
            "coding": [
              {
                "code": "eligible"
              }
            ]
          },
          "amount": {
            "value": 250,
            "currency": "USD"
          }
        },
        {
          "category": {
            "coding": [
              {
                "code": "copay"
              }
            ]
          },
          "amount": {
            "value": 10,
            "currency": "USD"
          }
        },
        {
          "category": {
            "coding": [
              {
                "code": "eligpercent"
              }
            ]
          },
          "value": 100
        },
        {
          "category": {
            "coding": [
              {
                "code": "benefit"
              }
            ]
          },
          "amount": {
            "value": 240,
            "currency": "USD"
          }
        }
      ]
    },
    {
      "itemSequence": [
        1
      ],
      "productOrService": {
        "coding": [
          {
            "system": "http://example.org/fhir/oralservicecodes",
            "code": "2101",
            "display": "Radiograph, series (12)"
          }
        ]
      },
      "net": {
        "value": 800,
        "currency": "USD"
      },
      "adjudication": [
        {
          "category": {
            "coding": [
              {
                "code": "eligible"
              }
            ]
          },
          "amount": {
            "value": 800,
            "currency": "USD"
          }
        },
        {
          "category": {
            "coding": [
              {
                "code": "eligpercent"
              }
            ]
          },
          "value": 100
        },
        {
          "category": {
            "coding": [
              {
                "code": "benefit"
              }
            ]
          },
          "amount": {
            "value": 800,
            "currency": "USD"
          }
        }
      ]
    }
  ],
  "total": [
    {
      "category": {
        "coding": [
          {
            "code": "submitted"
          }
        ]
      },
      "amount": {
        "value": 1050,
        "currency": "USD"
      }
    },
    {
      "category": {
        "coding": [
          {
            "code": "benefit"
          }
        ]
      },
      "amount": {
        "value": 1040,
        "currency": "USD"
      }
    }
  ],
  "processNote": [
    {
      "number": 101,
      "type": "print",
      "text": "Please submit a Pre-Authorization request if a more extensive examination or urgent services are required.",
      "language": {
        "coding": [
          {
            "system": "urn:ietf:bcp:47",
            "code": "en-CA"
          }
        ]
      }
    }
  ],
  "insurance": [
    {
      "sequence": 1,
      "focal": true,
      "coverage": {
        "reference": "Coverage/9876B1"
      }
    }
  ]
}
Example #5
Input CSV
ClaimResponse,5,"R3502","active","http://terminology.hl7.org/CodeSystem/claim-type",,"vision",,,,,,,,,,"claim","Patient/1",,,,,,,,,,,,,,"2014-08-16","Organization/2",,,,,,,,,,,,,,"Organization/1",,,,,,,,,,,,,,,,,,,,,,,"http://happysight.com/claim","6612346",,,,"complete","Claim settled as per contract.",,,,"http://terminology.hl7.org/CodeSystem/payeetype",,"provider",,,,"http://terminology.hl7.org/CodeSystem/ex-paymenttype",,"complete",,,,75,"USD","http://terminology.hl7.org/CodeSystem/payment-adjustment-reason",,"a002","Prior Overpayment",,,"2014-08-16",107,"USD",,,,,,,,"http://thebenefitcompany.com/paymentidentifier","201416-123456",,,,,,,,,,,,,,,,,,,,,,
identifier,,,,,,,,"http://thebenefitcompany.com/claimresponse","CR6532875367",,
item,1,,,,"eligible",,,,,,,,,,235.4,"USD",,1,1,,,"eligible",,,,,,,,,,100,"USD",,,,,,,,,,,,,,,,,,
total,,,"submitted",,,,235.4,"USD"
total,,,"benefit",,,,182,"USD"
processNote,1,"display","After hours surcharge declined","urn:ietf:bcp:47",,"en-CA",,,
Resulting resource
{
  "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,
            "currency": "USD"
          }
        },
        {
          "category": {
            "coding": [
              {
                "code": "eligpercent"
              }
            ]
          },
          "value": 80
        },
        {
          "category": {
            "coding": [
              {
                "code": "benefit"
              }
            ]
          },
          "amount": {
            "value": 172.32,
            "currency": "USD"
          }
        }
      ],
      "detail": [
        {
          "detailSequence": 1,
          "noteNumber": [
            1
          ],
          "adjudication": [
            {
              "category": {
                "coding": [
                  {
                    "code": "eligible"
                  }
                ]
              },
              "amount": {
                "value": 100,
                "currency": "USD"
              }
            },
            {
              "category": {
                "coding": [
                  {
                    "code": "copay"
                  }
                ]
              },
              "amount": {
                "value": 20,
                "currency": "USD"
              }
            },
            {
              "category": {
                "coding": [
                  {
                    "code": "eligpercent"
                  }
                ]
              },
              "value": 80
            },
            {
              "category": {
                "coding": [
                  {
                    "code": "benefit"
                  }
                ]
              },
              "amount": {
                "value": 80,
                "currency": "USD"
              }
            }
          ]
        },
        {
          "detailSequence": 2,
          "noteNumber": [
            1
          ],
          "adjudication": [
            {
              "category": {
                "coding": [
                  {
                    "code": "eligible"
                  }
                ]
              },
              "amount": {
                "value": 110,
                "currency": "USD"
              }
            },
            {
              "category": {
                "coding": [
                  {
                    "code": "eligpercent"
                  }
                ]
              },
              "value": 80
            },
            {
              "category": {
                "coding": [
                  {
                    "code": "benefit"
                  }
                ]
              },
              "amount": {
                "value": 88,
                "currency": "USD"
              }
            }
          ],
          "subDetail": [
            {
              "subDetailSequence": 1,
              "noteNumber": [
                1
              ],
              "adjudication": [
                {
                  "category": {
                    "coding": [
                      {
                        "code": "eligible"
                      }
                    ]
                  },
                  "amount": {
                    "value": 60,
                    "currency": "USD"
                  }
                },
                {
                  "category": {
                    "coding": [
                      {
                        "code": "eligpercent"
                      }
                    ]
                  },
                  "value": 80
                },
                {
                  "category": {
                    "coding": [
                      {
                        "code": "benefit"
                      }
                    ]
                  },
                  "amount": {
                    "value": 48,
                    "currency": "USD"
                  }
                }
              ]
            },
            {
              "subDetailSequence": 2,
              "adjudication": [
                {
                  "category": {
                    "coding": [
                      {
                        "code": "eligible"
                      }
                    ]
                  },
                  "amount": {
                    "value": 30,
                    "currency": "USD"
                  }
                },
                {
                  "category": {
                    "coding": [
                      {
                        "code": "eligpercent"
                      }
                    ]
                  },
                  "value": 80
                },
                {
                  "category": {
                    "coding": [
                      {
                        "code": "benefit"
                      }
                    ]
                  },
                  "amount": {
                    "value": 24,
                    "currency": "USD"
                  }
                }
              ]
            },
            {
              "subDetailSequence": 3,
              "noteNumber": [
                1
              ],
              "adjudication": [
                {
                  "category": {
                    "coding": [
                      {
                        "code": "eligible"
                      }
                    ]
                  },
                  "amount": {
                    "value": 10,
                    "currency": "USD"
                  }
                },
                {
                  "category": {
                    "coding": [
                      {
                        "code": "eligpercent"
                      }
                    ]
                  },
                  "value": 80
                },
                {
                  "category": {
                    "coding": [
                      {
                        "code": "benefit"
                      }
                    ]
                  },
                  "amount": {
                    "value": 8,
                    "currency": "USD"
                  }
                }
              ]
            }
          ]
        },
        {
          "detailSequence": 3,
          "noteNumber": [
            1
          ],
          "adjudication": [
            {
              "category": {
                "coding": [
                  {
                    "code": "eligible"
                  }
                ]
              },
              "amount": {
                "value": 200,
                "currency": "USD"
              }
            },
            {
              "category": {
                "coding": [
                  {
                    "code": "eligpercent"
                  }
                ]
              },
              "value": 80
            },
            {
              "category": {
                "coding": [
                  {
                    "code": "benefit"
                  }
                ]
              },
              "amount": {
                "value": 14,
                "currency": "USD"
              }
            }
          ]
        }
      ]
    }
  ],
  "total": [
    {
      "category": {
        "coding": [
          {
            "code": "submitted"
          }
        ]
      },
      "amount": {
        "value": 235.4,
        "currency": "USD"
      }
    },
    {
      "category": {
        "coding": [
          {
            "code": "benefit"
          }
        ]
      },
      "amount": {
        "value": 182,
        "currency": "USD"
      }
    }
  ],
  "payment": {
    "type": {
      "coding": [
        {
          "system": "http://terminology.hl7.org/CodeSystem/ex-paymenttype",
          "code": "complete"
        }
      ]
    },
    "adjustment": {
      "value": 75,
      "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,
      "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"
          }
        ]
      }
    }
  ]
}