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Claimresponse-example-2.xml

Financial Management Work Group Maturity Level : N/A Standards Status : Informative Compartments : Patient , Practitioner

Raw XML ( canonical form + also see XML Format Specification )

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A ClaimResponse for a Claim that contains processing errors (id = "R3501")

<?xml version="1.0" encoding="UTF-8"?>
<ClaimResponse xmlns="http://hl7.org/fhir">
  <id value="R3501"/> 
  <text> 
    <status value="generated"/> 
    <div xmlns="http://www.w3.org/1999/xhtml">A human-readable rendering of the ClaimResponse that demonstrates returning errors</div> 
  </text> 
  <identifier> 
    <system value="http://www.BenefitsInc.com/fhir/remittance"/> 
    <value value="R3501"/> 
  </identifier> 
  <status value="active"/> 
  <type> 
    <coding> 
      <system value="http://terminology.hl7.org/CodeSystem/claim-type"/> 
      <code value="oral"/> 
    </coding> 
  </type> 
  <use value="claim"/> 
  
  <patient> 
    

    <reference value="Patient/1"/> 
  </patient> 
  <created value="2014-08-16"/> 
  <insurer> 
    

    <identifier> 
      <system value="http://www.jurisdiction.org/insurers"/> 
      <value value="555123"/> 
    

    </identifier> 
  </insurer> 
  <requestor> 
    

    <reference value="Practitioner/1"/> 
  </requestor> 
  <request> 
    

    <reference value="Claim/100156"/> 
  </request> 
  <outcome value="error"/> 
  
  <disposition value="Claim could not be processed"/> 
  
  <formCode> 
    <coding> 
      <system value="http://terminology.hl7.org/CodeSystem/forms-codes"/> 
      <code value="2"/> 
    </coding> 
  </formCode> 
  
  <processNote> 
    <number value="1"/> 
    <type value="display"/> 
    <text value="Invalid claim"/> 
    <language> 
      <coding> 
        <system value="urn:ietf:bcp:47"/> 
        <code value="en-CA"/> 
      </coding> 
    </language> 
  </processNote> 
  
  <communicationRequest> 
    

    <reference value="CommunicationRequest/fm-solicit"/> 
  </communicationRequest> 
  
  <!--   Detailed error description   -->
  <error> 
    <itemSequence value="3"/> 
    <detailSequence value="2"/> 
    <code> 
      <coding> 
        <system value="http://terminology.hl7.org/CodeSystem/adjudication-error"/> 
        <code value="a002"/> 
      </coding> 
    </code> 
  </error> 


</

ClaimResponse

>



Usage note: every effort has been made to ensure that the examples are correct and useful, but they are not a normative part of the specification.