LinuxForHealth FHIR Implementation Guide
8.0.0 - draft
LinuxForHealth FHIR Implementation Guide - Local Development build (v8.0.0). See the Directory of published versions
<ClaimResponse xmlns="http://hl7.org/fhir">
<id value="CDMClaimResponseFacilityInstance"/>
<meta>
<extension
url="http://linuxforhealth.org/fhir/cdm/StructureDefinition/tenant-id">
<valueString value="tenant7209"/>
</extension>
<extension
url="http://linuxforhealth.org/fhir/cdm/StructureDefinition/ingestion-batch-id">
<valueString value="rgVCJnQBxvghkKTI8Hzz"/>
</extension>
<extension
url="http://linuxforhealth.org/fhir/cdm/StructureDefinition/process-name">
<valueString value="TREX"/>
</extension>
<extension
url="http://linuxforhealth.org/fhir/cdm/StructureDefinition/process-client-id">
<valueString value="7209"/>
</extension>
<extension
url="http://linuxforhealth.org/fhir/cdm/StructureDefinition/process-record-id">
<valueIdentifier>
<system value="http://acme-health.com/WellnessMedicalCenter"/>
<value value="7209_07869_e00080722_3938586_2516181"/>
</valueIdentifier>
</extension>
<extension
url="http://linuxforhealth.org/fhir/cdm/StructureDefinition/source-file-id">
<valueString value="e00080722"/>
</extension>
<source value="http://acme-health.com/WellnessMedicalCenter"/>
<profile
value="http://linuxforhealth.org/fhir/cdm/StructureDefinition/cdm-claim-response"/>
</meta>
<text>
<status value="extensions"/>
<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>
</text>
<extension
url="http://linuxforhealth.org/fhir/cdm/StructureDefinition/claim-received-date">
<valueDate value="2017-06-01"/>
</extension>
<extension
url="http://linuxforhealth.org/fhir/cdm/StructureDefinition/claim-status">
<valueCodeableConcept>
<coding>
<system value="http://acme-health.com/CodeSystem/local-claim-status"/>
<code value="LocClaimStatus"/>
</coding>
</valueCodeableConcept>
</extension>
<extension
url="http://linuxforhealth.org/fhir/cdm/StructureDefinition/days-to-process">
<valueInteger value="15"/>
</extension>
<identifier>
<use value="official"/>
<type>
<coding>
<system
value="http://linuxforhealth.org/fhir/cdm/CodeSystem/identifier-type"/>
<code value="SSRI"/>
</coding>
</type>
<system value="http://acme-health.com/CodeSystem/local-claim-identifier"/>
<value value="000000000000000000019721078"/>
<assigner>
<display value="Acme Health - Wellness Medical Center"/>
</assigner>
</identifier>
<status value="active"/>
<type>
<coding>
<system
value="http://linuxforhealth.org/fhir/cdm/CodeSystem/payer-claim-type"/>
<code value="medical"/>
</coding>
<coding>
<system value="http://acme-health.com/CodeSystem/local-claim-type"/>
<code value="MedicalClaimType"/>
</coding>
</type>
<use value="claim"/>
<patient>
<reference value="Patient/CDMPatientInstance"/>
</patient>
<created value="2017-07-25T17:31:00-05:00"/>
<insurer>
<type value="Organization"/>
<identifier>
<system value="http://acme-health.com/payer1/payer"/>
<value value="Payer1"/>
</identifier>
</insurer>
<outcome value="complete"/>
<item>
<extension
url="http://linuxforhealth.org/fhir/cdm/StructureDefinition/copay-exclusion">
<valueCodeableConcept>
<coding>
<system
value="http://acme-health.com/CodeSystem/local-copay-exclusion"/>
<code value="LocCopayExclusion"/>
</coding>
</valueCodeableConcept>
</extension>
<extension
url="http://linuxforhealth.org/fhir/cdm/StructureDefinition/number-of-units-allowed">
<valueInteger value="2"/>
</extension>
<extension
url="http://linuxforhealth.org/fhir/cdm/StructureDefinition/reinsurance-met-indicator">
<valueString value="Y"/>
</extension>
<extension
url="http://linuxforhealth.org/fhir/cdm/StructureDefinition/utilization-review">
<valueCodeableConcept>
<coding>
<system
value="http://acme-health.com/CodeSystem/local-utilization-review"/>
<code value="LocUtilizatinoReviewCd"/>
</coding>
</valueCodeableConcept>
</extension>
<itemSequence value="1"/>
<adjudication>
<category>
<coding>
<system
value="http://linuxforhealth.org/fhir/cdm/CodeSystem/adjudication-category"/>
<code value="coinsurance"/>
</coding>
</category>
<amount>
<value value="0"/>
<currency value="USD"/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system
value="http://linuxforhealth.org/fhir/cdm/CodeSystem/adjudication-category"/>
<code value="copay"/>
</coding>
</category>
<amount>
<value value="25"/>
<currency value="USD"/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system
value="http://linuxforhealth.org/fhir/cdm/CodeSystem/adjudication-category"/>
<code value="deductible"/>
</coding>
</category>
<amount>
<value value="0"/>
<currency value="USD"/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system
value="http://linuxforhealth.org/fhir/cdm/CodeSystem/adjudication-category"/>
<code value="tax"/>
</coding>
</category>
<amount>
<value value="1"/>
<currency value="USD"/>
</amount>
</adjudication>
<adjudication>
<extension
url="http://linuxforhealth.org/fhir/cdm/StructureDefinition/savings-type">
<valueCodeableConcept>
<coding>
<system
value="http://acme-health.com/CodeSystem/local-savings-type"/>
<code value="LocalSavingsType"/>
</coding>
</valueCodeableConcept>
</extension>
<category>
<coding>
<system
value="http://linuxforhealth.org/fhir/cdm/CodeSystem/adjudication-category"/>
<code value="third-party"/>
</coding>
</category>
<amount>
<value value="0"/>
<currency value="USD"/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system
value="http://linuxforhealth.org/fhir/cdm/CodeSystem/adjudication-category"/>
<code value="allowed"/>
</coding>
</category>
<amount>
<value value="125"/>
<currency value="USD"/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system
value="http://linuxforhealth.org/fhir/cdm/CodeSystem/adjudication-category"/>
<code value="submitted"/>
</coding>
</category>
<amount>
<value value="165"/>
<currency value="USD"/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system
value="http://linuxforhealth.org/fhir/cdm/CodeSystem/adjudication-category"/>
<code value="net-payment"/>
</coding>
</category>
<reason>
<coding>
<system
value="https://x12.org/codes/remittance-advice-remark-codes"/>
<code value="M2"/>
</coding>
<coding>
<system
value="https://x12.org/codes/remittance-advice-remark-codes"/>
<code value="N16"/>
</coding>
<coding>
<system
value="http://acme-health.com/CodeSystem/local-explanation-of-benefits"/>
<code value="LocalEOB"/>
</coding>
<coding>
<system
value="http://acme-health.com/CodeSystem/local-denied-reason"/>
<code value="LocalDeniedReason"/>
</coding>
</reason>
<amount>
<value value="100"/>
<currency value="USD"/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system
value="http://linuxforhealth.org/fhir/cdm/CodeSystem/adjudication-category"/>
<code value="discount"/>
</coding>
</category>
<amount>
<value value="40"/>
<currency value="USD"/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system
value="http://linuxforhealth.org/fhir/cdm/CodeSystem/adjudication-category"/>
<code value="discount"/>
</coding>
</category>
<reason>
<coding>
<system
value="http://acme-health.com/CodeSystem/local-discount-type"/>
<code value="LocalDiscountType"/>
</coding>
</reason>
<amount>
<value value="0"/>
<currency value="USD"/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system
value="http://linuxforhealth.org/fhir/cdm/CodeSystem/adjudication-category"/>
<code value="ffs-equivalent"/>
</coding>
</category>
<amount>
<value value="0"/>
<currency value="USD"/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system
value="http://linuxforhealth.org/fhir/cdm/CodeSystem/adjudication-category"/>
<code value="fully-insured-payment"/>
</coding>
</category>
<amount>
<value value="0"/>
<currency value="USD"/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system
value="http://linuxforhealth.org/fhir/cdm/CodeSystem/adjudication-category"/>
<code value="healthcare-reimbursement"/>
</coding>
</category>
<amount>
<value value="0"/>
<currency value="USD"/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system
value="http://linuxforhealth.org/fhir/cdm/CodeSystem/adjudication-category"/>
<code value="healthcare-savings-account"/>
</coding>
</category>
<amount>
<value value="0"/>
<currency value="USD"/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system
value="http://linuxforhealth.org/fhir/cdm/CodeSystem/adjudication-category"/>
<code value="medicare-allowed"/>
</coding>
</category>
<amount>
<value value="0"/>
<currency value="USD"/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system
value="http://linuxforhealth.org/fhir/cdm/CodeSystem/adjudication-category"/>
<code value="medicare-coinsurance"/>
</coding>
</category>
<amount>
<value value="0"/>
<currency value="USD"/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system
value="http://linuxforhealth.org/fhir/cdm/CodeSystem/adjudication-category"/>
<code value="medicare-deductible"/>
</coding>
</category>
<amount>
<value value="0"/>
<currency value="USD"/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system
value="http://linuxforhealth.org/fhir/cdm/CodeSystem/adjudication-category"/>
<code value="patient-liability"/>
</coding>
</category>
<amount>
<value value="0"/>
<currency value="USD"/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system
value="http://linuxforhealth.org/fhir/cdm/CodeSystem/adjudication-category"/>
<code value="penalty"/>
</coding>
</category>
<reason>
<coding>
<system
value="http://acme-health.com/CodeSystem/local-penalty-type"/>
<code value="LocPenaltyType"/>
</coding>
</reason>
</adjudication>
<adjudication>
<category>
<coding>
<system
value="http://linuxforhealth.org/fhir/cdm/CodeSystem/adjudication-category"/>
<code value="medicare-paid"/>
</coding>
</category>
<amount>
<value value="0"/>
<currency value="USD"/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system
value="http://linuxforhealth.org/fhir/cdm/CodeSystem/adjudication-category"/>
<code value="withhold"/>
</coding>
</category>
<amount>
<value value="0"/>
<currency value="USD"/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system
value="http://linuxforhealth.org/fhir/cdm/CodeSystem/adjudication-category"/>
<code value="excluded1"/>
</coding>
</category>
<reason>
<coding>
<system
value="http://acme-health.com/CodeSystem/local-excluded-reason_1"/>
<code value="LocalExcludedReason1"/>
</coding>
</reason>
<amount>
<value value="0"/>
<currency value="USD"/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system
value="http://linuxforhealth.org/fhir/cdm/CodeSystem/adjudication-category"/>
<code value="excluded2"/>
</coding>
</category>
<reason>
<coding>
<system
value="http://acme-health.com/CodeSystem/local-excluded-reason_2"/>
<code value="LocalExcludedReason2"/>
</coding>
</reason>
<amount>
<value value="0"/>
<currency value="USD"/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system
value="http://linuxforhealth.org/fhir/cdm/CodeSystem/adjudication-category"/>
<code value="excluded-reason"/>
</coding>
</category>
<reason>
<coding>
<system
value="http://acme-health.com/CodeSystem/local-excluded-reason_3"/>
<code value="LocalExcludedReason3"/>
</coding>
</reason>
</adjudication>
<adjudication>
<category>
<coding>
<system
value="http://linuxforhealth.org/fhir/cdm/CodeSystem/adjudication-category"/>
<code value="drg-outlier"/>
</coding>
</category>
<amount>
<value value="0"/>
<currency value="USD"/>
</amount>
</adjudication>
<adjudication>
<extension
url="http://linuxforhealth.org/fhir/cdm/StructureDefinition/routing-number-code">
<valueString value="12345"/>
</extension>
<category>
<coding>
<system
value="http://linuxforhealth.org/fhir/cdm/CodeSystem/adjudication-category"/>
<code value="out-of-network-access-fee"/>
</coding>
</category>
<amount>
<value value="0"/>
<currency value="USD"/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system
value="http://linuxforhealth.org/fhir/cdm/CodeSystem/adjudication-category"/>
<code value="out-of-network-surcharge-fee"/>
</coding>
</category>
<amount>
<value value="0"/>
<currency value="USD"/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system
value="http://linuxforhealth.org/fhir/cdm/CodeSystem/adjudication-category"/>
<code value="summary"/>
</coding>
</category>
<reason>
<coding>
<system
value="http://acme-health.com/CodeSystem/local-explanation-of-benefits"/>
<code value="LocalEOB1"/>
</coding>
<coding>
<system
value="http://acme-health.com/CodeSystem/local-explanation-of-benefits"/>
<code value="LocalEOB2"/>
</coding>
</reason>
</adjudication>
</item>
<adjudication>
<extension
url="http://linuxforhealth.org/fhir/cdm/StructureDefinition/adjudication-date">
<valueDate value="2017-06-30"/>
</extension>
<category>
<coding>
<system
value="http://linuxforhealth.org/fhir/cdm/CodeSystem/paid-in-network-indicator"/>
<code value="in-network"/>
</coding>
</category>
<reason>
<coding>
<system
value="http://linuxforhealth.org/fhir/cdm/CodeSystem/paid-in-network-indicator"/>
<code value="in-network"/>
</coding>
</reason>
</adjudication>
<payment>
<extension
url="http://linuxforhealth.org/fhir/cdm/StructureDefinition/claim-adjustment-type">
<valueCodeableConcept>
<coding>
<system
value="http://linuxforhealth.org/fhir/cdm/CodeSystem/payer-claim-adjustment-type"/>
<code value="1"/>
</coding>
</valueCodeableConcept>
</extension>
<extension
url="http://linuxforhealth.org/fhir/cdm/StructureDefinition/claim-adjustment-type">
<valueCodeableConcept>
<coding>
<system
value="http://acme-health.com/CodeSystem/local-claim-adjustment-type"/>
<code value="LocalClaimAdjType"/>
</coding>
</valueCodeableConcept>
</extension>
<extension
url="http://linuxforhealth.org/fhir/cdm/StructureDefinition/disposition-reason">
<valueCodeableConcept>
<coding>
<system
value="http://acme-health.com/CodeSystem/local-disposition-reason"/>
<code value="record-in-error-correct-and-resubmit"/>
</coding>
</valueCodeableConcept>
</extension>
<extension
url="http://linuxforhealth.org/fhir/cdm/StructureDefinition/reimburse-type">
<valueCodeableConcept>
<coding>
<system
value="http://acme-health.com/CodeSystem/local-reimburse-type"/>
<code value="LocalReimburseType"/>
</coding>
</valueCodeableConcept>
</extension>
<type>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/ex-paymenttype"/>
<code value="complete"/>
</coding>
</type>
<adjustmentReason>
<coding>
<system
value="http://acme-health.com/CodeSystem/local-adjustment-reason"/>
<code value="local-adj-reason"/>
</coding>
</adjustmentReason>
<date value="2017-07-20"/>
<amount>
<value value="5"/>
</amount>
</payment>
<error>
<code>
<coding>
<system value="http://acme-health.com/CodeSystem/local-error-detail"/>
<code value="LocErrorDetail1"/>
</coding>
</code>
</error>
<error>
<code>
<coding>
<system value="http://acme-health.com/CodeSystem/local-error-header"/>
<code value="LocErrorDetail2"/>
</coding>
</code>
</error>
<error>
<code>
<coding>
<system value="http://acme-health.com/CodeSystem/local-error-detail"/>
<code value="LocErrorDetail3"/>
</coding>
</code>
</error>
<error>
<code>
<coding>
<system value="http://acme-health.com/CodeSystem/local-error-detail"/>
<code value="LocErrorDetail4"/>
</coding>
</code>
</error>
<error>
<code>
<coding>
<system value="http://acme-health.com/CodeSystem/local-error-header"/>
<code value="LocErrorHeader1"/>
</coding>
</code>
</error>
<error>
<code>
<coding>
<system
value="http://acme-health.com/CodeSystem/local-exception-detail"/>
<code value="LocExceptionDetail1"/>
</coding>
</code>
</error>
<error>
<code>
<coding>
<system
value="http://acme-health.com/CodeSystem/local-exception-detail"/>
<code value="LocExceptionDetail2"/>
</coding>
</code>
</error>
<error>
<code>
<coding>
<system
value="http://acme-health.com/CodeSystem/local-exception-header"/>
<code value="LocExceptionHeader1"/>
</coding>
</code>
</error>
<error>
<code>
<coding>
<system
value="http://acme-health.com/CodeSystem/local-exception-header"/>
<code value="LocExceptionHeader2"/>
</coding>
</code>
</error>
</ClaimResponse>
IG © 2021+ LinuxForHealth Team. Package linuxforhealth.fhir.ig#8.0.0 based on FHIR 4.0.1. Generated 2022-11-10
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QA Report