FHIR Implementation Guide for HCX
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: HCX Claim Response Document example - JSON Representation

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{
  "resourceType" : "Bundle",
  "id" : "ClaimResponseDocument-example-01",
  "meta" : {
    "versionId" : "1",
    "lastUpdated" : "2021-12-22T15:32:26.605+05:30"
  },
  "identifier" : {
    "system" : "urn:ietf:rfc:3986",
    "value" : "urn:uuiad:9699444a"
  },
  "type" : "document",
  "timestamp" : "2021-12-22T15:32:26.605+05:30",
  "entry" : [
    {
      "fullUrl" : "Composition/1",
      "resource" : {
        "resourceType" : "Composition",
        "id" : "1",
        "meta" : {
          "versionId" : "1",
          "lastUpdated" : "2021-12-22T15:32:26.605+05:30"
        },
        "text" : {
          "status" : "generated",
          "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p><b>Generated Narrative: Composition</b><a name=\"1\"> </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 Composition \"1\" Version \"1\" Updated \"2021-12-22 03:32:26+0530\" </p></div><p><b>identifier</b>: id: urn:uuid:28b6b35e</p><p><b>status</b>: final</p><p><b>type</b>: Claim Response <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (document-types#HCXClaimResponse)</span></p><p><b>date</b>: 2021-12-22 03:32:26+0530</p><p><b>author</b>: <a href=\"#Practitioner_1\">See above (Practitioner/1: Dr. Sudhir Naik (PMJAY Gujrat))</a></p><p><b>title</b>: Claim Request</p><h3>Attesters</h3><table class=\"grid\"><tr><td>-</td><td><b>Mode</b></td><td><b>Time</b></td><td><b>Party</b></td></tr><tr><td>*</td><td>official</td><td>2021-12-22 02:10:14+0000</td><td><a href=\"#Organization_2\">See above (Organization/2: PMJAY, MoHFW, Govt Of India)</a></td></tr></table></div>"
        },
        "identifier" : {
          "system" : "urn:ietf:rfc:3986",
          "value" : "urn:uuid:28b6b35e"
        },
        "status" : "final",
        "type" : {
          "coding" : [
            {
              "system" : "https://hcx.org/document-types",
              "code" : "HCXClaimResponse",
              "display" : "Claim Response"
            }
          ],
          "text" : "Claim Response"
        },
        "subject" : {
          "reference" : "Patient/1",
          "display" : "Hina Patel"
        },
        "date" : "2021-12-22T15:32:26.605+05:30",
        "author" : [
          {
            "reference" : "Practitioner/1",
            "display" : "Dr. Sudhir Naik (PMJAY Gujrat)"
          }
        ],
        "title" : "Claim Request",
        "attester" : [
          {
            "mode" : "official",
            "time" : "2021-12-22T14:10:14Z",
            "party" : {
              "reference" : "Organization/2",
              "display" : "PMJAY, MoHFW, Govt Of India"
            }
          }
        ],
        "section" : [
          {
            "title" : "Claim Response",
            "code" : {
              "coding" : [
                {
                  "system" : "https://www.hl7.org/fhir/valueset-resource-types",
                  "code" : "ClaimResponse",
                  "display" : "Claim Response"
                }
              ],
              "text" : "ClaimResponse"
            },
            "entry" : [
              {
                "reference" : "ClaimResponse/res-id-1"
              }
            ]
          }
        ]
      }
    },
    {
      "fullUrl" : "ClaimResponse/ress-id-1",
      "resource" : {
        "resourceType" : "ClaimResponse",
        "id" : "1355110",
        "meta" : {
          "versionId" : "1",
          "lastUpdated" : "2020-07-03T22:50:39.698+00:00",
          "source" : "#JrkobxCRdZUI6QNh"
        },
        "text" : {
          "status" : "generated",
          "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p><b>Generated Narrative: ClaimResponse</b><a name=\"1355110\"> </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 \"1355110\" Version \"1\" Updated \"2020-07-03 10:50:39+0000\" </p><p style=\"margin-bottom: 0px\">Information Source: #JrkobxCRdZUI6QNh!</p></div><p><b>status</b>: active</p><p><b>type</b>: institutional <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> ([not stated]#institutional)</span></p><p><b>use</b>: preauthorization</p><p><b>patient</b>: <a href=\"Patient/1353519\">Patient/1353519</a></p><p><b>created</b>: 2020-07-03 06:50:39-0400</p><p><b>insurer</b>: <a href=\"Organization/185\">Organization/185</a></p><p><b>request</b>: <a href=\"Claim/1355109\">Claim/1355109</a></p><p><b>outcome</b>: complete</p><blockquote><p><b>item</b></p><p><b>itemSequence</b>: 1</p><blockquote><p><b>adjudication</b></p><p><b>category</b>: eligible <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> ([not stated]#eligible)</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>500000</td><td>INR</td></tr></table></blockquote><blockquote><p><b>adjudication</b></p><p><b>category</b>: copay <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> ([not stated]#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>50000</td><td>INR</td></tr></table></blockquote><blockquote><p><b>adjudication</b></p><p><b>category</b>: eligpercent <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> ([not stated]#eligpercent)</span></p><p><b>value</b>: 80.00</p></blockquote><blockquote><p><b>adjudication</b></p><p><b>category</b>: benefit <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> ([not stated]#benefit)</span></p><p><b>reason</b>: Plan Limit Reached <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"http://terminology.hl7.org/4.0.0/CodeSystem-adjudication-reason.html\">Adjudication Reason Codes</a>#ar002)</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>360000</td><td>INR</td></tr></table></blockquote></blockquote><blockquote><p><b>total</b></p><p><b>category</b>: submitted <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> ([not stated]#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>500000</td><td>INR</td></tr></table></blockquote><blockquote><p><b>total</b></p><p><b>category</b>: benefit <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> ([not stated]#benefit)</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>360000</td><td>INR</td></tr></table></blockquote><blockquote><p><b>payment</b></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>date</b>: 2014-08-31</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>410000</td><td>INR</td></tr></table><p><b>identifier</b>: id: 201408-2-1569478</p></blockquote></div>"
        },
        "status" : "active",
        "type" : {
          "coding" : [
            {
              "code" : "institutional"
            }
          ]
        },
        "use" : "preauthorization",
        "patient" : {
          "reference" : "Patient/1353519",
          "type" : "Patient"
        },
        "created" : "2020-07-03T18:50:39-04:00",
        "insurer" : {
          "reference" : "Organization/185",
          "type" : "Organization"
        },
        "request" : {
          "reference" : "Claim/1355109"
        },
        "outcome" : "complete",
        "item" : [
          {
            "itemSequence" : 1,
            "adjudication" : [
              {
                "category" : {
                  "coding" : [
                    {
                      "code" : "eligible"
                    }
                  ]
                },
                "amount" : {
                  "value" : 500000,
                  "currency" : "INR"
                }
              },
              {
                "category" : {
                  "coding" : [
                    {
                      "code" : "copay"
                    }
                  ]
                },
                "amount" : {
                  "value" : 50000,
                  "currency" : "INR"
                }
              },
              {
                "category" : {
                  "coding" : [
                    {
                      "code" : "eligpercent"
                    }
                  ]
                },
                "value" : 80.00
              },
              {
                "category" : {
                  "coding" : [
                    {
                      "code" : "benefit"
                    }
                  ]
                },
                "reason" : {
                  "coding" : [
                    {
                      "system" : "http://terminology.hl7.org/CodeSystem/adjudication-reason",
                      "code" : "ar002",
                      "display" : "Plan Limit Reached"
                    }
                  ]
                },
                "amount" : {
                  "value" : 360000,
                  "currency" : "INR"
                }
              }
            ]
          }
        ],
        "total" : [
          {
            "category" : {
              "coding" : [
                {
                  "code" : "submitted"
                }
              ]
            },
            "amount" : {
              "value" : 500000,
              "currency" : "INR"
            }
          },
          {
            "category" : {
              "coding" : [
                {
                  "code" : "benefit"
                }
              ]
            },
            "amount" : {
              "value" : 360000,
              "currency" : "INR"
            }
          }
        ],
        "payment" : {
          "type" : {
            "coding" : [
              {
                "system" : "http://terminology.hl7.org/CodeSystem/ex-paymenttype",
                "code" : "complete"
              }
            ]
          },
          "date" : "2014-08-31",
          "amount" : {
            "value" : 410000,
            "currency" : "INR"
          },
          "identifier" : {
            "system" : "http://www.BenefitsInc.com/fhir/paymentidentifier",
            "value" : "201408-2-1569478"
          }
        }
      }
    },
    {
      "fullUrl" : "Patient/1",
      "resource" : {
        "resourceType" : "Patient",
        "id" : "1",
        "text" : {
          "status" : "generated",
          "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p><b>Generated Narrative: Patient</b><a name=\"1\"> </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 Patient \"1\" </p></div><p><b>identifier</b>: PHRADDR: 654321, PMJAYID: QWRT12345</p><p><b>name</b>: Hina Patel (OFFICIAL)</p><p><b>gender</b>: female</p><p><b>birthDate</b>: 1974-12-25</p></div>"
        },
        "identifier" : [
          {
            "type" : {
              "coding" : [
                {
                  "system" : "http://ndhm.gov.in/ValueSet/identifier-type",
                  "code" : "PHRADDR"
                }
              ]
            },
            "system" : "http://ndhm.gov.in/healthId",
            "value" : "654321"
          },
          {
            "type" : {
              "coding" : [
                {
                  "system" : "http://ndhm.gov.in/ValueSet/identifier-type",
                  "code" : "PMJAYID"
                }
              ]
            },
            "system" : "http://ndhm.gov.in/pmjay",
            "value" : "QWRT12345"
          }
        ],
        "name" : [
          {
            "use" : "official",
            "family" : "Patel",
            "given" : [
              "Hina"
            ]
          }
        ],
        "gender" : "female",
        "birthDate" : "1974-12-25"
      }
    },
    {
      "fullUrl" : "Organization/MaxSaket01",
      "resource" : {
        "resourceType" : "Organization",
        "id" : "MaxSaket01",
        "text" : {
          "status" : "generated",
          "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p><b>Generated Narrative: Organization</b><a name=\"MaxSaket01\"> </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 Organization \"MaxSaket01\" </p></div><p><b>identifier</b>: id: HFR-10000005</p><p><b>name</b>: Max Super Speciality Hospital, Saket</p></div>"
        },
        "identifier" : [
          {
            "system" : "https://ndhm.gov.in/hfr",
            "value" : "HFR-10000005"
          }
        ],
        "name" : "Max Super Speciality Hospital, Saket"
      }
    },
    {
      "fullUrl" : "Organization/2",
      "resource" : {
        "resourceType" : "Organization",
        "id" : "2",
        "text" : {
          "status" : "generated",
          "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p><b>Generated Narrative: Organization</b><a name=\"2\"> </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 Organization \"2\" </p></div><p><b>identifier</b>: id: PMJAY</p><p><b>name</b>: PMJAY, MoHFW, Govt Of India</p></div>"
        },
        "identifier" : [
          {
            "system" : "https://hcx.org/orgs",
            "value" : "PMJAY"
          }
        ],
        "name" : "PMJAY, MoHFW, Govt Of India"
      }
    },
    {
      "fullUrl" : "Practitioner/1",
      "resource" : {
        "resourceType" : "Practitioner",
        "id" : "1",
        "text" : {
          "status" : "generated",
          "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p><b>Generated Narrative: Practitioner</b><a name=\"1\"> </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 Practitioner \"1\" </p></div><p><b>identifier</b>: id: NPR-6897</p><p><b>name</b>: Sudhir Naik (PMJAY Gujrat)</p></div>"
        },
        "identifier" : [
          {
            "system" : "https://ndhm.gov.in/npr",
            "value" : "NPR-6897"
          }
        ],
        "name" : [
          {
            "text" : "Sudhir Naik (PMJAY Gujrat)",
            "prefix" : [
              "Dr"
            ],
            "suffix" : [
              "MD"
            ]
          }
        ]
      }
    }
  ]
}