LinuxForHealth FHIR Implementation Guide
8.0.0 - draft
LinuxForHealth FHIR Implementation Guide - Local Development build (v8.0.0). See the Directory of published versions
{
"resourceType" : "ClaimResponse",
"id" : "CDMClaimResponseFacilityInstance",
"meta" : {
"extension" : [
{
"url" : "http://linuxforhealth.org/fhir/cdm/StructureDefinition/tenant-id",
"valueString" : "tenant7209"
},
{
"url" : "http://linuxforhealth.org/fhir/cdm/StructureDefinition/ingestion-batch-id",
"valueString" : "rgVCJnQBxvghkKTI8Hzz"
},
{
"url" : "http://linuxforhealth.org/fhir/cdm/StructureDefinition/process-name",
"valueString" : "TREX"
},
{
"url" : "http://linuxforhealth.org/fhir/cdm/StructureDefinition/process-client-id",
"valueString" : "7209"
},
{
"url" : "http://linuxforhealth.org/fhir/cdm/StructureDefinition/process-record-id",
"valueIdentifier" : {
"system" : "http://acme-health.com/WellnessMedicalCenter",
"value" : "7209_07869_e00080722_3938586_2516181"
}
},
{
"url" : "http://linuxforhealth.org/fhir/cdm/StructureDefinition/source-file-id",
"valueString" : "e00080722"
}
],
"source" : "http://acme-health.com/WellnessMedicalCenter",
"profile" : [
"http://linuxforhealth.org/fhir/cdm/StructureDefinition/cdm-claim-response"
]
},
"text" : {
"status" : "extensions",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p><b>Generated Narrative: ClaimResponse</b><a name=\"CDMClaimResponseFacilityInstance\"> </a></p><div style=\"display: inline-block; background-color: #d9e0e7; padding: 6px; margin: 4px; border: 1px solid #8da1b4; border-radius: 5px; line-height: 60%\"><p style=\"margin-bottom: 0px\">Resource ClaimResponse \"CDMClaimResponseFacilityInstance\" </p><p style=\"margin-bottom: 0px\">Information Source: http://acme-health.com/WellnessMedicalCenter!</p><p style=\"margin-bottom: 0px\">Profile: <a href=\"StructureDefinition-cdm-claim-response.html\">CDM Claim Response</a></p></div><p><b>Claim Received Date</b>: 2017-06-01</p><p><b>Claim Status</b>: LocClaimStatus <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (local-claim-status#LocClaimStatus)</span></p><p><b>Days To Process</b>: 15</p><p><b>identifier</b>: Source System Row Identifier: 000000000000000000019721078(use: OFFICIAL)</p><p><b>status</b>: active</p><p><b>type</b>: Medical claim; Institutional/Professional unknown <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-payer-claim-type.html\">Payer Claim Type Codes</a>#medical; local-claim-type#MedicalClaimType)</span></p><p><b>use</b>: claim</p><p><b>patient</b>: <a href=\"Patient-CDMPatientInstance.html\">Patient/CDMPatientInstance</a> \" MCLASTNAME\"</p><p><b>created</b>: 2017-07-25 05:31:00-0500</p><p><b>insurer</b>: <span></span></p><p><b>outcome</b>: complete</p><blockquote><p><b>item</b></p><p><b>Copay Exclusion</b>: LocCopayExclusion <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (local-copay-exclusion#LocCopayExclusion)</span></p><p><b>Number of Units Allowed</b>: 2</p><p><b>Reinsurance Met Indicator</b>: Y</p><p><b>Utilization Review</b>: LocUtilizatinoReviewCd <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (local-utilization-review#LocUtilizatinoReviewCd)</span></p><p><b>itemSequence</b>: 1</p><blockquote><p><b>adjudication</b></p><p><b>category</b>: Coinsurance <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-adjudication-category.html\">Adjudication Category Codes</a>#coinsurance)</span></p><h3>Amounts</h3><table class=\"grid\"><tr><td>-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td>*</td><td>0</td><td>USD</td></tr></table></blockquote><blockquote><p><b>adjudication</b></p><p><b>category</b>: Copayment <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-adjudication-category.html\">Adjudication Category Codes</a>#copay)</span></p><h3>Amounts</h3><table class=\"grid\"><tr><td>-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td>*</td><td>25</td><td>USD</td></tr></table></blockquote><blockquote><p><b>adjudication</b></p><p><b>category</b>: Deductible Amount <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-adjudication-category.html\">Adjudication Category Codes</a>#deductible)</span></p><h3>Amounts</h3><table class=\"grid\"><tr><td>-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td>*</td><td>0</td><td>USD</td></tr></table></blockquote><blockquote><p><b>adjudication</b></p><p><b>category</b>: Tax Amount <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-adjudication-category.html\">Adjudication Category Codes</a>#tax)</span></p><h3>Amounts</h3><table class=\"grid\"><tr><td>-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td>*</td><td>1</td><td>USD</td></tr></table></blockquote><blockquote><p><b>adjudication</b></p><p><b>Savings Type</b>: LocalSavingsType <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (local-savings-type#LocalSavingsType)</span></p><p><b>category</b>: Third Party Amount <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-adjudication-category.html\">Adjudication Category Codes</a>#third-party)</span></p><h3>Amounts</h3><table class=\"grid\"><tr><td>-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td>*</td><td>0</td><td>USD</td></tr></table></blockquote><blockquote><p><b>adjudication</b></p><p><b>category</b>: Allowed Amount <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-adjudication-category.html\">Adjudication Category Codes</a>#allowed)</span></p><h3>Amounts</h3><table class=\"grid\"><tr><td>-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td>*</td><td>125</td><td>USD</td></tr></table></blockquote><blockquote><p><b>adjudication</b></p><p><b>category</b>: Submitted <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-adjudication-category.html\">Adjudication Category Codes</a>#submitted)</span></p><h3>Amounts</h3><table class=\"grid\"><tr><td>-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td>*</td><td>165</td><td>USD</td></tr></table></blockquote><blockquote><p><b>adjudication</b></p><p><b>category</b>: Net Payment <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-adjudication-category.html\">Adjudication Category Codes</a>#net-payment)</span></p><p><b>reason</b>: M2 <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"http://terminology.hl7.org/4.0.0/CodeSystem-RARC.html\">X12 Remittance Advice Remark Codes</a>#M2; <a href=\"http://terminology.hl7.org/4.0.0/CodeSystem-RARC.html\">X12 Remittance Advice Remark Codes</a>#N16; local-explanation-of-benefits#LocalEOB; local-denied-reason#LocalDeniedReason)</span></p><h3>Amounts</h3><table class=\"grid\"><tr><td>-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td>*</td><td>100</td><td>USD</td></tr></table></blockquote><blockquote><p><b>adjudication</b></p><p><b>category</b>: Discount Amount <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-adjudication-category.html\">Adjudication Category Codes</a>#discount)</span></p><h3>Amounts</h3><table class=\"grid\"><tr><td>-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td>*</td><td>40</td><td>USD</td></tr></table></blockquote><blockquote><p><b>adjudication</b></p><p><b>category</b>: Discount Amount <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-adjudication-category.html\">Adjudication Category Codes</a>#discount)</span></p><p><b>reason</b>: LocalDiscountType <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (local-discount-type#LocalDiscountType)</span></p><h3>Amounts</h3><table class=\"grid\"><tr><td>-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td>*</td><td>0</td><td>USD</td></tr></table></blockquote><blockquote><p><b>adjudication</b></p><p><b>category</b>: Fee For Service Equivalent <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-adjudication-category.html\">Adjudication Category Codes</a>#ffs-equivalent)</span></p><h3>Amounts</h3><table class=\"grid\"><tr><td>-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td>*</td><td>0</td><td>USD</td></tr></table></blockquote><blockquote><p><b>adjudication</b></p><p><b>category</b>: Fully Insured Payment <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-adjudication-category.html\">Adjudication Category Codes</a>#fully-insured-payment)</span></p><h3>Amounts</h3><table class=\"grid\"><tr><td>-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td>*</td><td>0</td><td>USD</td></tr></table></blockquote><blockquote><p><b>adjudication</b></p><p><b>category</b>: Healthcare Reimbursement Amount <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-adjudication-category.html\">Adjudication Category Codes</a>#healthcare-reimbursement)</span></p><h3>Amounts</h3><table class=\"grid\"><tr><td>-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td>*</td><td>0</td><td>USD</td></tr></table></blockquote><blockquote><p><b>adjudication</b></p><p><b>category</b>: Healthcare Savings Account <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-adjudication-category.html\">Adjudication Category Codes</a>#healthcare-savings-account)</span></p><h3>Amounts</h3><table class=\"grid\"><tr><td>-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td>*</td><td>0</td><td>USD</td></tr></table></blockquote><blockquote><p><b>adjudication</b></p><p><b>category</b>: Medicare Allowed Amount <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-adjudication-category.html\">Adjudication Category Codes</a>#medicare-allowed)</span></p><h3>Amounts</h3><table class=\"grid\"><tr><td>-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td>*</td><td>0</td><td>USD</td></tr></table></blockquote><blockquote><p><b>adjudication</b></p><p><b>category</b>: Medicare Coinsurance Amount <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-adjudication-category.html\">Adjudication Category Codes</a>#medicare-coinsurance)</span></p><h3>Amounts</h3><table class=\"grid\"><tr><td>-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td>*</td><td>0</td><td>USD</td></tr></table></blockquote><blockquote><p><b>adjudication</b></p><p><b>category</b>: Medicare Deductible Amount <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-adjudication-category.html\">Adjudication Category Codes</a>#medicare-deductible)</span></p><h3>Amounts</h3><table class=\"grid\"><tr><td>-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td>*</td><td>0</td><td>USD</td></tr></table></blockquote><blockquote><p><b>adjudication</b></p><p><b>category</b>: Patient Liability <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-adjudication-category.html\">Adjudication Category Codes</a>#patient-liability)</span></p><h3>Amounts</h3><table class=\"grid\"><tr><td>-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td>*</td><td>0</td><td>USD</td></tr></table></blockquote><blockquote><p><b>adjudication</b></p><p><b>category</b>: Penalty <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-adjudication-category.html\">Adjudication Category Codes</a>#penalty)</span></p><p><b>reason</b>: LocPenaltyType <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (local-penalty-type#LocPenaltyType)</span></p></blockquote><blockquote><p><b>adjudication</b></p><p><b>category</b>: Medicare Paid Amount <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-adjudication-category.html\">Adjudication Category Codes</a>#medicare-paid)</span></p><h3>Amounts</h3><table class=\"grid\"><tr><td>-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td>*</td><td>0</td><td>USD</td></tr></table></blockquote><blockquote><p><b>adjudication</b></p><p><b>category</b>: Risk Withhold <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-adjudication-category.html\">Adjudication Category Codes</a>#withhold)</span></p><h3>Amounts</h3><table class=\"grid\"><tr><td>-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td>*</td><td>0</td><td>USD</td></tr></table></blockquote><blockquote><p><b>adjudication</b></p><p><b>category</b>: Excluded Amount 1 <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-adjudication-category.html\">Adjudication Category Codes</a>#excluded1)</span></p><p><b>reason</b>: LocalExcludedReason1 <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (local-excluded-reason_1#LocalExcludedReason1)</span></p><h3>Amounts</h3><table class=\"grid\"><tr><td>-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td>*</td><td>0</td><td>USD</td></tr></table></blockquote><blockquote><p><b>adjudication</b></p><p><b>category</b>: Excluded Amount 2 <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-adjudication-category.html\">Adjudication Category Codes</a>#excluded2)</span></p><p><b>reason</b>: LocalExcludedReason2 <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (local-excluded-reason_2#LocalExcludedReason2)</span></p><h3>Amounts</h3><table class=\"grid\"><tr><td>-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td>*</td><td>0</td><td>USD</td></tr></table></blockquote><blockquote><p><b>adjudication</b></p><p><b>category</b>: Excluded Reason <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-adjudication-category.html\">Adjudication Category Codes</a>#excluded-reason)</span></p><p><b>reason</b>: LocalExcludedReason3 <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (local-excluded-reason_3#LocalExcludedReason3)</span></p></blockquote><blockquote><p><b>adjudication</b></p><p><b>category</b>: DRG Outlier <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-adjudication-category.html\">Adjudication Category Codes</a>#drg-outlier)</span></p><h3>Amounts</h3><table class=\"grid\"><tr><td>-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td>*</td><td>0</td><td>USD</td></tr></table></blockquote><blockquote><p><b>adjudication</b></p><p><b>Routing Number Code</b>: 12345</p><p><b>category</b>: ITS Access Fee (Out of Network Access Fee) <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-adjudication-category.html\">Adjudication Category Codes</a>#out-of-network-access-fee)</span></p><h3>Amounts</h3><table class=\"grid\"><tr><td>-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td>*</td><td>0</td><td>USD</td></tr></table></blockquote><blockquote><p><b>adjudication</b></p><p><b>category</b>: ITS Surcharge Amount (Out of Network Surcharge Amount) <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-adjudication-category.html\">Adjudication Category Codes</a>#out-of-network-surcharge-fee)</span></p><h3>Amounts</h3><table class=\"grid\"><tr><td>-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td>*</td><td>0</td><td>USD</td></tr></table></blockquote><blockquote><p><b>adjudication</b></p><p><b>category</b>: Summary <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-adjudication-category.html\">Adjudication Category Codes</a>#summary)</span></p><p><b>reason</b>: LocalEOB1 <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (local-explanation-of-benefits#LocalEOB1; local-explanation-of-benefits#LocalEOB2)</span></p></blockquote></blockquote><h3>Adjudications</h3><table class=\"grid\"><tr><td>-</td><td><b>Extension</b></td><td><b>Category</b></td><td><b>Reason</b></td></tr><tr><td>*</td><td></td><td>In Network <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-paid-in-network-indicator.html\">Paid In Network Indicator Codes</a>#in-network)</span></td><td>In Network <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-paid-in-network-indicator.html\">Paid In Network Indicator Codes</a>#in-network)</span></td></tr></table><blockquote><p><b>payment</b></p><p><b>Claim Adjustment Type</b>: Adjustment (positive or negative adjustment) <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-payer-claim-adjustment-type.html\">Payer Claim Adjustment Type Codes</a>#1)</span></p><p><b>Claim Adjustment Type</b>: LocalClaimAdjType <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (local-claim-adjustment-type#LocalClaimAdjType)</span></p><p><b>Disposition Reason</b>: record-in-error-correct-and-resubmit <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (local-disposition-reason#record-in-error-correct-and-resubmit)</span></p><p><b>Reimburse Type</b>: LocalReimburseType <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (local-reimburse-type#LocalReimburseType)</span></p><p><b>type</b>: Complete <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"http://terminology.hl7.org/4.0.0/CodeSystem-ex-paymenttype.html\">Example Payment Type Codes</a>#complete)</span></p><p><b>adjustmentReason</b>: local-adj-reason <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (local-adjustment-reason#local-adj-reason)</span></p><p><b>date</b>: 2017-07-20</p><h3>Amounts</h3><table class=\"grid\"><tr><td>-</td><td><b>Value</b></td></tr><tr><td>*</td><td>5</td></tr></table></blockquote><blockquote><p><b>error</b></p><p><b>code</b>: LocErrorDetail1 <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (local-error-detail#LocErrorDetail1)</span></p></blockquote><blockquote><p><b>error</b></p><p><b>code</b>: LocErrorDetail2 <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (local-error-header#LocErrorDetail2)</span></p></blockquote><blockquote><p><b>error</b></p><p><b>code</b>: LocErrorDetail3 <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (local-error-detail#LocErrorDetail3)</span></p></blockquote><blockquote><p><b>error</b></p><p><b>code</b>: LocErrorDetail4 <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (local-error-detail#LocErrorDetail4)</span></p></blockquote><blockquote><p><b>error</b></p><p><b>code</b>: LocErrorHeader1 <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (local-error-header#LocErrorHeader1)</span></p></blockquote><blockquote><p><b>error</b></p><p><b>code</b>: LocExceptionDetail1 <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (local-exception-detail#LocExceptionDetail1)</span></p></blockquote><blockquote><p><b>error</b></p><p><b>code</b>: LocExceptionDetail2 <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (local-exception-detail#LocExceptionDetail2)</span></p></blockquote><blockquote><p><b>error</b></p><p><b>code</b>: LocExceptionHeader1 <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (local-exception-header#LocExceptionHeader1)</span></p></blockquote><blockquote><p><b>error</b></p><p><b>code</b>: LocExceptionHeader2 <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (local-exception-header#LocExceptionHeader2)</span></p></blockquote></div>"
},
"extension" : [
{
"url" : "http://linuxforhealth.org/fhir/cdm/StructureDefinition/claim-received-date",
"valueDate" : "2017-06-01"
},
{
"url" : "http://linuxforhealth.org/fhir/cdm/StructureDefinition/claim-status",
"valueCodeableConcept" : {
"coding" : [
{
"system" : "http://acme-health.com/CodeSystem/local-claim-status",
"code" : "LocClaimStatus"
}
]
}
},
{
"url" : "http://linuxforhealth.org/fhir/cdm/StructureDefinition/days-to-process",
"valueInteger" : 15
}
],
"identifier" : [
{
"use" : "official",
"type" : {
"coding" : [
{
"system" : "http://linuxforhealth.org/fhir/cdm/CodeSystem/identifier-type",
"code" : "SSRI"
}
]
},
"system" : "http://acme-health.com/CodeSystem/local-claim-identifier",
"value" : "000000000000000000019721078",
"assigner" : {
"display" : "Acme Health - Wellness Medical Center"
}
}
],
"status" : "active",
"type" : {
"coding" : [
{
"system" : "http://linuxforhealth.org/fhir/cdm/CodeSystem/payer-claim-type",
"code" : "medical"
},
{
"system" : "http://acme-health.com/CodeSystem/local-claim-type",
"code" : "MedicalClaimType"
}
]
},
"use" : "claim",
"patient" : {
"reference" : "Patient/CDMPatientInstance"
},
"created" : "2017-07-25T17:31:00-05:00",
"insurer" : {
"type" : "Organization",
"identifier" : {
"system" : "http://acme-health.com/payer1/payer",
"value" : "Payer1"
}
},
"outcome" : "complete",
"item" : [
{
"extension" : [
{
"url" : "http://linuxforhealth.org/fhir/cdm/StructureDefinition/copay-exclusion",
"valueCodeableConcept" : {
"coding" : [
{
"system" : "http://acme-health.com/CodeSystem/local-copay-exclusion",
"code" : "LocCopayExclusion"
}
]
}
},
{
"url" : "http://linuxforhealth.org/fhir/cdm/StructureDefinition/number-of-units-allowed",
"valueInteger" : 2
},
{
"url" : "http://linuxforhealth.org/fhir/cdm/StructureDefinition/reinsurance-met-indicator",
"valueString" : "Y"
},
{
"url" : "http://linuxforhealth.org/fhir/cdm/StructureDefinition/utilization-review",
"valueCodeableConcept" : {
"coding" : [
{
"system" : "http://acme-health.com/CodeSystem/local-utilization-review",
"code" : "LocUtilizatinoReviewCd"
}
]
}
}
],
"itemSequence" : 1,
"adjudication" : [
{
"category" : {
"coding" : [
{
"system" : "http://linuxforhealth.org/fhir/cdm/CodeSystem/adjudication-category",
"code" : "coinsurance"
}
]
},
"amount" : {
"value" : 0,
"currency" : "USD"
}
},
{
"category" : {
"coding" : [
{
"system" : "http://linuxforhealth.org/fhir/cdm/CodeSystem/adjudication-category",
"code" : "copay"
}
]
},
"amount" : {
"value" : 25,
"currency" : "USD"
}
},
{
"category" : {
"coding" : [
{
"system" : "http://linuxforhealth.org/fhir/cdm/CodeSystem/adjudication-category",
"code" : "deductible"
}
]
},
"amount" : {
"value" : 0,
"currency" : "USD"
}
},
{
"category" : {
"coding" : [
{
"system" : "http://linuxforhealth.org/fhir/cdm/CodeSystem/adjudication-category",
"code" : "tax"
}
]
},
"amount" : {
"value" : 1,
"currency" : "USD"
}
},
{
"extension" : [
{
"url" : "http://linuxforhealth.org/fhir/cdm/StructureDefinition/savings-type",
"valueCodeableConcept" : {
"coding" : [
{
"system" : "http://acme-health.com/CodeSystem/local-savings-type",
"code" : "LocalSavingsType"
}
]
}
}
],
"category" : {
"coding" : [
{
"system" : "http://linuxforhealth.org/fhir/cdm/CodeSystem/adjudication-category",
"code" : "third-party"
}
]
},
"amount" : {
"value" : 0,
"currency" : "USD"
}
},
{
"category" : {
"coding" : [
{
"system" : "http://linuxforhealth.org/fhir/cdm/CodeSystem/adjudication-category",
"code" : "allowed"
}
]
},
"amount" : {
"value" : 125,
"currency" : "USD"
}
},
{
"category" : {
"coding" : [
{
"system" : "http://linuxforhealth.org/fhir/cdm/CodeSystem/adjudication-category",
"code" : "submitted"
}
]
},
"amount" : {
"value" : 165,
"currency" : "USD"
}
},
{
"category" : {
"coding" : [
{
"system" : "http://linuxforhealth.org/fhir/cdm/CodeSystem/adjudication-category",
"code" : "net-payment"
}
]
},
"reason" : {
"coding" : [
{
"system" : "https://x12.org/codes/remittance-advice-remark-codes",
"code" : "M2"
},
{
"system" : "https://x12.org/codes/remittance-advice-remark-codes",
"code" : "N16"
},
{
"system" : "http://acme-health.com/CodeSystem/local-explanation-of-benefits",
"code" : "LocalEOB"
},
{
"system" : "http://acme-health.com/CodeSystem/local-denied-reason",
"code" : "LocalDeniedReason"
}
]
},
"amount" : {
"value" : 100,
"currency" : "USD"
}
},
{
"category" : {
"coding" : [
{
"system" : "http://linuxforhealth.org/fhir/cdm/CodeSystem/adjudication-category",
"code" : "discount"
}
]
},
"amount" : {
"value" : 40,
"currency" : "USD"
}
},
{
"category" : {
"coding" : [
{
"system" : "http://linuxforhealth.org/fhir/cdm/CodeSystem/adjudication-category",
"code" : "discount"
}
]
},
"reason" : {
"coding" : [
{
"system" : "http://acme-health.com/CodeSystem/local-discount-type",
"code" : "LocalDiscountType"
}
]
},
"amount" : {
"value" : 0,
"currency" : "USD"
}
},
{
"category" : {
"coding" : [
{
"system" : "http://linuxforhealth.org/fhir/cdm/CodeSystem/adjudication-category",
"code" : "ffs-equivalent"
}
]
},
"amount" : {
"value" : 0,
"currency" : "USD"
}
},
{
"category" : {
"coding" : [
{
"system" : "http://linuxforhealth.org/fhir/cdm/CodeSystem/adjudication-category",
"code" : "fully-insured-payment"
}
]
},
"amount" : {
"value" : 0,
"currency" : "USD"
}
},
{
"category" : {
"coding" : [
{
"system" : "http://linuxforhealth.org/fhir/cdm/CodeSystem/adjudication-category",
"code" : "healthcare-reimbursement"
}
]
},
"amount" : {
"value" : 0,
"currency" : "USD"
}
},
{
"category" : {
"coding" : [
{
"system" : "http://linuxforhealth.org/fhir/cdm/CodeSystem/adjudication-category",
"code" : "healthcare-savings-account"
}
]
},
"amount" : {
"value" : 0,
"currency" : "USD"
}
},
{
"category" : {
"coding" : [
{
"system" : "http://linuxforhealth.org/fhir/cdm/CodeSystem/adjudication-category",
"code" : "medicare-allowed"
}
]
},
"amount" : {
"value" : 0,
"currency" : "USD"
}
},
{
"category" : {
"coding" : [
{
"system" : "http://linuxforhealth.org/fhir/cdm/CodeSystem/adjudication-category",
"code" : "medicare-coinsurance"
}
]
},
"amount" : {
"value" : 0,
"currency" : "USD"
}
},
{
"category" : {
"coding" : [
{
"system" : "http://linuxforhealth.org/fhir/cdm/CodeSystem/adjudication-category",
"code" : "medicare-deductible"
}
]
},
"amount" : {
"value" : 0,
"currency" : "USD"
}
},
{
"category" : {
"coding" : [
{
"system" : "http://linuxforhealth.org/fhir/cdm/CodeSystem/adjudication-category",
"code" : "patient-liability"
}
]
},
"amount" : {
"value" : 0,
"currency" : "USD"
}
},
{
"category" : {
"coding" : [
{
"system" : "http://linuxforhealth.org/fhir/cdm/CodeSystem/adjudication-category",
"code" : "penalty"
}
]
},
"reason" : {
"coding" : [
{
"system" : "http://acme-health.com/CodeSystem/local-penalty-type",
"code" : "LocPenaltyType"
}
]
}
},
{
"category" : {
"coding" : [
{
"system" : "http://linuxforhealth.org/fhir/cdm/CodeSystem/adjudication-category",
"code" : "medicare-paid"
}
]
},
"amount" : {
"value" : 0,
"currency" : "USD"
}
},
{
"category" : {
"coding" : [
{
"system" : "http://linuxforhealth.org/fhir/cdm/CodeSystem/adjudication-category",
"code" : "withhold"
}
]
},
"amount" : {
"value" : 0,
"currency" : "USD"
}
},
{
"category" : {
"coding" : [
{
"system" : "http://linuxforhealth.org/fhir/cdm/CodeSystem/adjudication-category",
"code" : "excluded1"
}
]
},
"reason" : {
"coding" : [
{
"system" : "http://acme-health.com/CodeSystem/local-excluded-reason_1",
"code" : "LocalExcludedReason1"
}
]
},
"amount" : {
"value" : 0,
"currency" : "USD"
}
},
{
"category" : {
"coding" : [
{
"system" : "http://linuxforhealth.org/fhir/cdm/CodeSystem/adjudication-category",
"code" : "excluded2"
}
]
},
"reason" : {
"coding" : [
{
"system" : "http://acme-health.com/CodeSystem/local-excluded-reason_2",
"code" : "LocalExcludedReason2"
}
]
},
"amount" : {
"value" : 0,
"currency" : "USD"
}
},
{
"category" : {
"coding" : [
{
"system" : "http://linuxforhealth.org/fhir/cdm/CodeSystem/adjudication-category",
"code" : "excluded-reason"
}
]
},
"reason" : {
"coding" : [
{
"system" : "http://acme-health.com/CodeSystem/local-excluded-reason_3",
"code" : "LocalExcludedReason3"
}
]
}
},
{
"category" : {
"coding" : [
{
"system" : "http://linuxforhealth.org/fhir/cdm/CodeSystem/adjudication-category",
"code" : "drg-outlier"
}
]
},
"amount" : {
"value" : 0,
"currency" : "USD"
}
},
{
"extension" : [
{
"url" : "http://linuxforhealth.org/fhir/cdm/StructureDefinition/routing-number-code",
"valueString" : "12345"
}
],
"category" : {
"coding" : [
{
"system" : "http://linuxforhealth.org/fhir/cdm/CodeSystem/adjudication-category",
"code" : "out-of-network-access-fee"
}
]
},
"amount" : {
"value" : 0,
"currency" : "USD"
}
},
{
"category" : {
"coding" : [
{
"system" : "http://linuxforhealth.org/fhir/cdm/CodeSystem/adjudication-category",
"code" : "out-of-network-surcharge-fee"
}
]
},
"amount" : {
"value" : 0,
"currency" : "USD"
}
},
{
"category" : {
"coding" : [
{
"system" : "http://linuxforhealth.org/fhir/cdm/CodeSystem/adjudication-category",
"code" : "summary"
}
]
},
"reason" : {
"coding" : [
{
"system" : "http://acme-health.com/CodeSystem/local-explanation-of-benefits",
"code" : "LocalEOB1"
},
{
"system" : "http://acme-health.com/CodeSystem/local-explanation-of-benefits",
"code" : "LocalEOB2"
}
]
}
}
]
}
],
"adjudication" : [
{
"extension" : [
{
"url" : "http://linuxforhealth.org/fhir/cdm/StructureDefinition/adjudication-date",
"valueDate" : "2017-06-30"
}
],
"category" : {
"coding" : [
{
"system" : "http://linuxforhealth.org/fhir/cdm/CodeSystem/paid-in-network-indicator",
"code" : "in-network"
}
]
},
"reason" : {
"coding" : [
{
"system" : "http://linuxforhealth.org/fhir/cdm/CodeSystem/paid-in-network-indicator",
"code" : "in-network"
}
]
}
}
],
"payment" : {
"extension" : [
{
"url" : "http://linuxforhealth.org/fhir/cdm/StructureDefinition/claim-adjustment-type",
"valueCodeableConcept" : {
"coding" : [
{
"system" : "http://linuxforhealth.org/fhir/cdm/CodeSystem/payer-claim-adjustment-type",
"code" : "1"
}
]
}
},
{
"url" : "http://linuxforhealth.org/fhir/cdm/StructureDefinition/claim-adjustment-type",
"valueCodeableConcept" : {
"coding" : [
{
"system" : "http://acme-health.com/CodeSystem/local-claim-adjustment-type",
"code" : "LocalClaimAdjType"
}
]
}
},
{
"url" : "http://linuxforhealth.org/fhir/cdm/StructureDefinition/disposition-reason",
"valueCodeableConcept" : {
"coding" : [
{
"system" : "http://acme-health.com/CodeSystem/local-disposition-reason",
"code" : "record-in-error-correct-and-resubmit"
}
]
}
},
{
"url" : "http://linuxforhealth.org/fhir/cdm/StructureDefinition/reimburse-type",
"valueCodeableConcept" : {
"coding" : [
{
"system" : "http://acme-health.com/CodeSystem/local-reimburse-type",
"code" : "LocalReimburseType"
}
]
}
}
],
"type" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/ex-paymenttype",
"code" : "complete"
}
]
},
"adjustmentReason" : {
"coding" : [
{
"system" : "http://acme-health.com/CodeSystem/local-adjustment-reason",
"code" : "local-adj-reason"
}
]
},
"date" : "2017-07-20",
"amount" : {
"value" : 5
}
},
"error" : [
{
"code" : {
"coding" : [
{
"system" : "http://acme-health.com/CodeSystem/local-error-detail",
"code" : "LocErrorDetail1"
}
]
}
},
{
"code" : {
"coding" : [
{
"system" : "http://acme-health.com/CodeSystem/local-error-header",
"code" : "LocErrorDetail2"
}
]
}
},
{
"code" : {
"coding" : [
{
"system" : "http://acme-health.com/CodeSystem/local-error-detail",
"code" : "LocErrorDetail3"
}
]
}
},
{
"code" : {
"coding" : [
{
"system" : "http://acme-health.com/CodeSystem/local-error-detail",
"code" : "LocErrorDetail4"
}
]
}
},
{
"code" : {
"coding" : [
{
"system" : "http://acme-health.com/CodeSystem/local-error-header",
"code" : "LocErrorHeader1"
}
]
}
},
{
"code" : {
"coding" : [
{
"system" : "http://acme-health.com/CodeSystem/local-exception-detail",
"code" : "LocExceptionDetail1"
}
]
}
},
{
"code" : {
"coding" : [
{
"system" : "http://acme-health.com/CodeSystem/local-exception-detail",
"code" : "LocExceptionDetail2"
}
]
}
},
{
"code" : {
"coding" : [
{
"system" : "http://acme-health.com/CodeSystem/local-exception-header",
"code" : "LocExceptionHeader1"
}
]
}
},
{
"code" : {
"coding" : [
{
"system" : "http://acme-health.com/CodeSystem/local-exception-header",
"code" : "LocExceptionHeader2"
}
]
}
}
]
}
IG © 2021+ LinuxForHealth Team. Package linuxforhealth.fhir.ig#8.0.0 based on FHIR 4.0.1. Generated 2022-11-10
Links: Table of Contents |
QA Report