LinuxForHealth FHIR Implementation Guide
8.0.0 - draft United States of America flag

LinuxForHealth FHIR Implementation Guide - Local Development build (v8.0.0). See the Directory of published versions

: CDM Claim Response - Professional Example - JSON Representation

Raw json | Download


{
  "resourceType" : "ClaimResponse",
  "id" : "CDMClaimResponseProfessionalInstance",
  "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_e00080779_3938586_2516181"
        }
      },
      {
        "url" : "http://linuxforhealth.org/fhir/cdm/StructureDefinition/source-file-id",
        "valueString" : "e00080739"
      }
    ],
    "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=\"CDMClaimResponseProfessionalInstance\"> </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 \"CDMClaimResponseProfessionalInstance\" </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 Status</b>: LocalClaimStatus <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (local-claim-status#LocalClaimStatus)</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><p><b>preAuthRef</b>: Y</p><blockquote><p><b>item</b></p><p><b>Copay Exclusion</b>: LocalCopayExclusion <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (local-copay-exclusion#LocalCopayExclusion)</span></p><p><b>Number of Units Allowed</b>: 2</p><p><b>Reinsurance Met Indicator</b>: Y</p><p><b>Utilization Review</b>: LocalUtilizationReviewCd <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (local-utilization-review#LocalUtilizationReviewCd)</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>: 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>: LocalEOB <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (local-explanation-of-benefits#LocalEOB)</span></p></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>: 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>: LocalPenaltyType <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (local-penalty-type#LocalPenaltyType)</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>: 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>: 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><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><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 3 <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-adjudication-category.html\">Adjudication Category Codes</a>#excluded3)</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 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>: 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>: LocalExcludedReason1 <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (local-excluded-reason#LocalExcludedReason1)</span></p></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>: LocalExcludedReason2 <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (local-excluded-reason#LocalExcludedReason2)</span></p></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#LocalExcludedReason3)</span></p></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></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></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><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>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>100</td></tr></table></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>: LocErrorHeader2 <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (local-error-header#LocErrorHeader2)</span></p></blockquote><blockquote><p><b>error</b></p><p><b>itemSequence</b>: 1</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>itemSequence</b>: 2</p><p><b>code</b>: LocErrorDetail2 <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (local-error-detail#LocErrorDetail2)</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><blockquote><p><b>error</b></p><p><b>itemSequence</b>: 3</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>itemSequence</b>: 4</p><p><b>code</b>: LocExceptionDetail2 <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (local-exception-detail#LocExceptionDetail2)</span></p></blockquote></div>"
  },
  "extension" : [
    {
      "url" : "http://linuxforhealth.org/fhir/cdm/StructureDefinition/claim-status",
      "valueCodeableConcept" : {
        "coding" : [
          {
            "system" : "http://acme-health.com/CodeSystem/local-claim-status",
            "code" : "LocalClaimStatus"
          }
        ]
      }
    },
    {
      "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",
  "preAuthRef" : "Y",
  "item" : [
    {
      "extension" : [
        {
          "url" : "http://linuxforhealth.org/fhir/cdm/StructureDefinition/copay-exclusion",
          "valueCodeableConcept" : {
            "coding" : [
              {
                "system" : "http://acme-health.com/CodeSystem/local-copay-exclusion",
                "code" : "LocalCopayExclusion"
              }
            ]
          }
        },
        {
          "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" : "LocalUtilizationReviewCd"
              }
            ]
          }
        }
      ],
      "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" : "summary"
              }
            ]
          },
          "reason" : {
            "coding" : [
              {
                "system" : "http://acme-health.com/CodeSystem/local-explanation-of-benefits",
                "code" : "LocalEOB"
              }
            ]
          }
        },
        {
          "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" : "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" : "LocalPenaltyType"
              }
            ]
          },
          "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" : "medicare-paid"
              }
            ]
          },
          "amount" : {
            "value" : 0,
            "currency" : "USD"
          }
        },
        {
          "category" : {
            "coding" : [
              {
                "system" : "http://linuxforhealth.org/fhir/cdm/CodeSystem/adjudication-category",
                "code" : "excluded1"
              }
            ]
          },
          "amount" : {
            "value" : 0,
            "currency" : "USD"
          }
        },
        {
          "category" : {
            "coding" : [
              {
                "system" : "http://linuxforhealth.org/fhir/cdm/CodeSystem/adjudication-category",
                "code" : "excluded2"
              }
            ]
          },
          "amount" : {
            "value" : 0,
            "currency" : "USD"
          }
        },
        {
          "category" : {
            "coding" : [
              {
                "system" : "http://linuxforhealth.org/fhir/cdm/CodeSystem/adjudication-category",
                "code" : "excluded3"
              }
            ]
          },
          "amount" : {
            "value" : 0,
            "currency" : "USD"
          }
        },
        {
          "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" : "excluded-reason"
              }
            ]
          },
          "reason" : {
            "coding" : [
              {
                "system" : "http://acme-health.com/CodeSystem/local-excluded-reason",
                "code" : "LocalExcludedReason1"
              }
            ]
          }
        },
        {
          "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",
                "code" : "LocalExcludedReason2"
              }
            ]
          }
        },
        {
          "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",
                "code" : "LocalExcludedReason3"
              }
            ]
          }
        },
        {
          "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"
              }
            ]
          }
        },
        {
          "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"
              }
            ]
          }
        },
        {
          "category" : {
            "coding" : [
              {
                "system" : "http://linuxforhealth.org/fhir/cdm/CodeSystem/adjudication-category",
                "code" : "tax"
              }
            ]
          },
          "amount" : {
            "value" : 1,
            "currency" : "USD"
          }
        }
      ]
    }
  ],
  "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"
            }
          ]
        }
      }
    ],
    "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" : 100
    }
  },
  "error" : [
    {
      "code" : {
        "coding" : [
          {
            "system" : "http://acme-health.com/CodeSystem/local-error-header",
            "code" : "LocErrorHeader1"
          }
        ]
      }
    },
    {
      "code" : {
        "coding" : [
          {
            "system" : "http://acme-health.com/CodeSystem/local-error-header",
            "code" : "LocErrorHeader2"
          }
        ]
      }
    },
    {
      "itemSequence" : 1,
      "code" : {
        "coding" : [
          {
            "system" : "http://acme-health.com/CodeSystem/local-error-detail",
            "code" : "LocErrorDetail1"
          }
        ]
      }
    },
    {
      "itemSequence" : 2,
      "code" : {
        "coding" : [
          {
            "system" : "http://acme-health.com/CodeSystem/local-error-detail",
            "code" : "LocErrorDetail2"
          }
        ]
      }
    },
    {
      "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"
          }
        ]
      }
    },
    {
      "itemSequence" : 3,
      "code" : {
        "coding" : [
          {
            "system" : "http://acme-health.com/CodeSystem/local-exception-detail",
            "code" : "LocExceptionDetail1"
          }
        ]
      }
    },
    {
      "itemSequence" : 4,
      "code" : {
        "coding" : [
          {
            "system" : "http://acme-health.com/CodeSystem/local-exception-detail",
            "code" : "LocExceptionDetail2"
          }
        ]
      }
    }
  ]
}