LinuxForHealth FHIR Implementation Guide
8.0.0 - draft
LinuxForHealth FHIR Implementation Guide
8.0.0 - draft
LinuxForHealth FHIR Implementation Guide - Local Development build (v8.0.0). See the Directory of published versions
Generated Narrative: ClaimResponse
Resource ClaimResponse "CDMClaimResponseDrugInstance"
Information Source: http://acme-health.com/WellnessCenterPharmacy!
Profile: CDM Claim Response Drug
Claim Status: LocClaimSts (local-claim-status#LocClaimSts)
Claim Received Date: 2017-06-01
identifier: Prescription Number: 000000000000000000019721078(use: OFFICIAL)
status: active
type: Pharmacy; Pharmacy claims for goods and services (Payer Claim Type Codes#pharmacy; local-claim-type#Pharmacy)
use: claim
patient: Patient/CDMPatientInstance " MCLASTNAME"
created: 2017-07-25 05:31:00-0500
insurer:
outcome: complete
item
Claim Response Item Status: Paid (Payer Claim Status Codes#P)
Claim Response Benefit Plan: Coverage/CoverageDrugExample
Rx Formulary Indicator: N
Rx Pay Tier: Tier1 (local-rx-pay-tier#Tier1)
Rx Supply Indicator: N
Usual And Customary Amount: 0
itemSequence: 1
adjudication
category: Coinsurance (Adjudication Category Codes#coinsurance)
Amounts
- Value * 18.86 adjudication
category: Copayment (Adjudication Category Codes#copay)
Amounts
- Value * 10 adjudication
category: Deductible Amount (Adjudication Category Codes#deductible)
Amounts
- Value * 10 adjudication
category: Tax Amount (Adjudication Category Codes#tax)
Amounts
- Value * 1.01 adjudication
category: Third Party Amount (Adjudication Category Codes#third-party)
Amounts
- Value * 0 adjudication
category: Allowed Amount (Adjudication Category Codes#allowed)
Amounts
- Value * 25 adjudication
category: Submitted (Adjudication Category Codes#submitted)
Amounts
- Value * 5 adjudication
category: Net Payment (Adjudication Category Codes#net-payment)
reason: M50 (X12 Remittance Advice Remark Codes#M50; X12 Remittance Advice Remark Codes#N423)
Amounts
- Value * 0 adjudication
category: Discount Amount (Adjudication Category Codes#discount)
Amounts
- Value * 0 adjudication
category: Fee For Service Equivalent (Adjudication Category Codes#ffs-equivalent)
Amounts
- Value * 0 adjudication
category: Fully Insured Payment (Adjudication Category Codes#fully-insured-payment)
Amounts
- Value * 0 adjudication
category: Healthcare Reimbursement Amount (Adjudication Category Codes#healthcare-reimbursement)
Amounts
- Value * 0 adjudication
category: Healthcare Savings Account (Adjudication Category Codes#healthcare-savings-account)
Amounts
- Value * 0 adjudication
category: Medicare Allowed Amount (Adjudication Category Codes#medicare-allowed)
Amounts
- Value * 0 adjudication
category: Medicare Coinsurance Amount (Adjudication Category Codes#medicare-coinsurance)
Amounts
- Value * 0 adjudication
category: Medicare Deductible Amount (Adjudication Category Codes#medicare-deductible)
Amounts
- Value * 0 adjudication
category: Patient Liability (Adjudication Category Codes#patient-liability)
Amounts
- Value * 0 adjudication
category: Penalty (Adjudication Category Codes#penalty)
reason: LocPenaltyType (local-penalty-type#LocPenaltyType)
Amounts
- Value * 1 adjudication
category: Excess Copayment (Adjudication Category Codes#excess_copay)
Amounts
- Value * 0 adjudication
category: Medicare Paid Amount (Adjudication Category Codes#medicare-paid)
Amounts
- Value * 0
| - | Extension | Category |
| * | In Network (Paid In Network Indicator Codes#in-network) |
payment
Claim Adjustment Type: Adjustment (positive or negative adjustment) (Payer Claim Adjustment Type Codes#1)
Claim Adjustment Type: LocalClaimAdjType (local-claim-adjustment-type#LocalClaimAdjType)
Disposition Reason: record-in-error-correct-and-resubmit (local-disposition-reason#record-in-error-correct-and-resubmit)
type: Complete (Example Payment Type Codes#complete)
adjustmentReason: local-adj-reason (local-adjustment-reason#local-adj-reason)
date: 2017-07-20
Amounts
- Value * 5