Generated Narrative: ClaimResponse

Claim Status: LocalClaimStatus (local-claim-status#LocalClaimStatus)

Days To Process: 15

identifier: Source System Row Identifier: 000000000000000000019721078(use: OFFICIAL)

status: active

type: Medical claim; Institutional/Professional unknown (Payer Claim Type Codes#medical; local-claim-type#MedicalClaimType)

use: claim

patient: Patient/CDMPatientInstance " MCLASTNAME"

created: 2017-07-25 05:31:00-0500

insurer:

outcome: complete

preAuthRef: Y

item

Copay Exclusion: LocalCopayExclusion (local-copay-exclusion#LocalCopayExclusion)

Number of Units Allowed: 2

Reinsurance Met Indicator: Y

Utilization Review: LocalUtilizationReviewCd (local-utilization-review#LocalUtilizationReviewCd)

itemSequence: 1

adjudication

category: Coinsurance (Adjudication Category Codes#coinsurance)

Amounts

-	Value	Currency
*	0	USD

adjudication

category: Copayment (Adjudication Category Codes#copay)

Amounts

-	Value	Currency
*	25	USD

adjudication

category: Deductible Amount (Adjudication Category Codes#deductible)

Amounts

-	Value	Currency
*	0	USD

adjudication

category: Summary (Adjudication Category Codes#summary)

reason: LocalEOB (local-explanation-of-benefits#LocalEOB)

adjudication

Savings Type: LocalSavingsType (local-savings-type#LocalSavingsType)

category: Third Party Amount (Adjudication Category Codes#third-party)

Amounts

-	Value	Currency
*	0	USD

adjudication

category: Allowed Amount (Adjudication Category Codes#allowed)

Amounts

-	Value	Currency
*	125	USD

adjudication

category: Submitted (Adjudication Category Codes#submitted)

Amounts

-	Value	Currency
*	165	USD

adjudication

category: Net Payment (Adjudication Category Codes#net-payment)

reason: M2 (X12 Remittance Advice Remark Codes#M2; X12 Remittance Advice Remark Codes#N16; local-explanation-of-benefits#LocalEOB; local-denied-reason#LocalDeniedReason)

Amounts

-	Value	Currency
*	100	USD

adjudication

category: Discount Amount (Adjudication Category Codes#discount)

Amounts

-	Value	Currency
*	40	USD

adjudication

category: Fee For Service Equivalent (Adjudication Category Codes#ffs-equivalent)

Amounts

-	Value	Currency
*	0	USD

adjudication

category: Fully Insured Payment (Adjudication Category Codes#fully-insured-payment)

Amounts

-	Value	Currency
*	0	USD

adjudication

category: Healthcare Reimbursement Amount (Adjudication Category Codes#healthcare-reimbursement)

Amounts

-	Value	Currency
*	0	USD

adjudication

category: Healthcare Savings Account (Adjudication Category Codes#healthcare-savings-account)

Amounts

-	Value	Currency
*	0	USD

adjudication

category: Medicare Allowed Amount (Adjudication Category Codes#medicare-allowed)

Amounts

-	Value	Currency
*	0	USD

adjudication

category: Medicare Coinsurance Amount (Adjudication Category Codes#medicare-coinsurance)

Amounts

-	Value	Currency
*	0	USD

adjudication

category: Medicare Deductible Amount (Adjudication Category Codes#medicare-deductible)

Amounts

-	Value	Currency
*	0	USD

adjudication

category: Patient Liability (Adjudication Category Codes#patient-liability)

Amounts

-	Value	Currency
*	0	USD

adjudication

category: Penalty (Adjudication Category Codes#penalty)

reason: LocalPenaltyType (local-penalty-type#LocalPenaltyType)

Amounts

-	Value	Currency
*	0	USD

adjudication

category: Risk Withhold (Adjudication Category Codes#withhold)

Amounts

-	Value	Currency
*	0	USD

adjudication

category: Medicare Paid Amount (Adjudication Category Codes#medicare-paid)

Amounts

-	Value	Currency
*	0	USD

adjudication

category: Excluded Amount 1 (Adjudication Category Codes#excluded1)

Amounts

-	Value	Currency
*	0	USD

adjudication

category: Excluded Amount 2 (Adjudication Category Codes#excluded2)

Amounts

-	Value	Currency
*	0	USD

adjudication

category: Excluded Amount 3 (Adjudication Category Codes#excluded3)

Amounts

-	Value	Currency
*	0	USD

adjudication

category: ITS Access Fee (Out of Network Access Fee) (Adjudication Category Codes#out-of-network-access-fee)

Amounts

-	Value	Currency
*	0	USD

adjudication

category: ITS Surcharge Amount (Out of Network Surcharge Amount) (Adjudication Category Codes#out-of-network-surcharge-fee)

Amounts

-	Value	Currency
*	0	USD

adjudication

category: Excluded Reason (Adjudication Category Codes#excluded-reason)

reason: LocalExcludedReason1 (local-excluded-reason#LocalExcludedReason1)

adjudication

category: Excluded Reason (Adjudication Category Codes#excluded-reason)

reason: LocalExcludedReason2 (local-excluded-reason#LocalExcludedReason2)

adjudication

category: Excluded Reason (Adjudication Category Codes#excluded-reason)

reason: LocalExcludedReason3 (local-excluded-reason#LocalExcludedReason3)

adjudication

category: Discount Amount (Adjudication Category Codes#discount)

reason: LocalDiscountType (local-discount-type#LocalDiscountType)

adjudication

Routing Number Code: 12345

category: ITS Access Fee (Out of Network Access Fee) (Adjudication Category Codes#out-of-network-access-fee)

adjudication

category: Tax Amount (Adjudication Category Codes#tax)

Amounts

-	Value	Currency
*	1	USD

Adjudications

payment

Claim Adjustment Type: Adjustment (positive or negative adjustment) (Payer Claim Adjustment Type Codes#1)

Claim Adjustment Type: LocalClaimAdjType (local-claim-adjustment-type#LocalClaimAdjType)

type: Complete (Example Payment Type Codes#complete)

adjustmentReason: local-adj-reason (local-adjustment-reason#local-adj-reason)

date: 2017-07-20

Amounts

-	Value
*	100

error

code: LocErrorHeader1 (local-error-header#LocErrorHeader1)

error

code: LocErrorHeader2 (local-error-header#LocErrorHeader2)

error

itemSequence: 1

code: LocErrorDetail1 (local-error-detail#LocErrorDetail1)

error

itemSequence: 2

code: LocErrorDetail2 (local-error-detail#LocErrorDetail2)

error

code: LocExceptionHeader1 (local-exception-header#LocExceptionHeader1)

error

code: LocExceptionHeader2 (local-exception-header#LocExceptionHeader2)

error

itemSequence: 3

code: LocExceptionDetail1 (local-exception-detail#LocExceptionDetail1)

error

itemSequence: 4

code: LocExceptionDetail2 (local-exception-detail#LocExceptionDetail2)