FHIR Implementation Guide for HCX
0.7.0 - CI Build

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: HCX Claim Response example - JSON Representation

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{
  "resourceType" : "ClaimResponse",
  "id" : "example-01",
  "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=\"example-01\"> </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 \"example-01\" Version \"1\" Updated \"2020-07-03 10:50:39+0000\" </p><p style=\"margin-bottom: 0px\">Information Source: #JrkobxCRdZUI6QNh!</p></div><p><b>identifier</b>: id: dc82673b-8c71-48c2-2k9s-16dcb3b829m2</p><p><b>status</b>: active</p><p><b>type</b>: Institutional <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"http://terminology.hl7.org/4.0.0/CodeSystem-claim-type.html\">Claim Type Codes</a>#institutional)</span></p><p><b>use</b>: preauthorization</p><p><b>patient</b>: <span></span></p><p><b>created</b>: 2020-07-03 06:50:39-0400</p><p><b>insurer</b>: <span></span></p><p><b>requestor</b>: <span></span></p><p><b>request</b>: <span></span></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 Amount <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"http://terminology.hl7.org/4.0.0/CodeSystem-adjudication.html\">Adjudication Value Codes</a>#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\"> (<a href=\"http://terminology.hl7.org/4.0.0/CodeSystem-adjudication.html\">Adjudication Value 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>50000</td><td>INR</td></tr></table></blockquote><blockquote><p><b>adjudication</b></p><p><b>category</b>: Eligible % <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"http://terminology.hl7.org/4.0.0/CodeSystem-adjudication.html\">Adjudication Value Codes</a>#eligpercent)</span></p><p><b>value</b>: 80.00</p></blockquote><blockquote><p><b>adjudication</b></p><p><b>category</b>: Benefit Amount <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"http://terminology.hl7.org/4.0.0/CodeSystem-adjudication.html\">Adjudication Value Codes</a>#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 Amount <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"http://terminology.hl7.org/4.0.0/CodeSystem-adjudication.html\">Adjudication Value 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>500000</td><td>INR</td></tr></table></blockquote><blockquote><p><b>total</b></p><p><b>category</b>: Benefit Amount <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"http://terminology.hl7.org/4.0.0/CodeSystem-adjudication.html\">Adjudication Value Codes</a>#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>"
  },
  "identifier" : [
    {
      "system" : "https://www.tmh.in/claim-response",
      "value" : "dc82673b-8c71-48c2-2k9s-16dcb3b829m2"
    }
  ],
  "status" : "active",
  "type" : {
    "coding" : [
      {
        "system" : "http://terminology.hl7.org/CodeSystem/claim-type",
        "code" : "institutional"
      }
    ]
  },
  "use" : "preauthorization",
  "patient" : {
    "id" : "RVH1003",
    "identifier" : {
      "type" : {
        "coding" : [
          {
            "system" : "http://terminology.hl7.org/CodeSystem/v2-0203",
            "code" : "SN",
            "display" : "Subscriber Number"
          }
        ]
      },
      "system" : "http://gicofIndia.com/beneficiaries",
      "value" : "BEN-101"
    }
  },
  "created" : "2020-07-03T18:50:39-04:00",
  "insurer" : {
    "id" : "GICOFINDIA",
    "identifier" : {
      "system" : "http://irdai.gov.in/insurers",
      "value" : "112"
    }
  },
  "requestor" : {
    "id" : "Tmh01",
    "identifier" : {
      "system" : "http://abdm.gov.in/facilities",
      "value" : "HFR-ID-FOR-TMH"
    }
  },
  "request" : {
    "id" : "example-01",
    "identifier" : {
      "system" : "https://www.tmh.in/claim-request",
      "value" : "dc82673b-8c71-29js-8a17-16dj3i20352n"
    }
  },
  "outcome" : "complete",
  "item" : [
    {
      "itemSequence" : 1,
      "adjudication" : [
        {
          "category" : {
            "coding" : [
              {
                "system" : "http://terminology.hl7.org/CodeSystem/adjudication",
                "code" : "eligible"
              }
            ]
          },
          "amount" : {
            "value" : 500000,
            "currency" : "INR"
          }
        },
        {
          "category" : {
            "coding" : [
              {
                "system" : "http://terminology.hl7.org/CodeSystem/adjudication",
                "code" : "copay"
              }
            ]
          },
          "amount" : {
            "value" : 50000,
            "currency" : "INR"
          }
        },
        {
          "category" : {
            "coding" : [
              {
                "system" : "http://terminology.hl7.org/CodeSystem/adjudication",
                "code" : "eligpercent"
              }
            ]
          },
          "value" : 80.00
        },
        {
          "category" : {
            "coding" : [
              {
                "system" : "http://terminology.hl7.org/CodeSystem/adjudication",
                "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" : [
          {
            "system" : "http://terminology.hl7.org/CodeSystem/adjudication",
            "code" : "submitted"
          }
        ]
      },
      "amount" : {
        "value" : 500000,
        "currency" : "INR"
      }
    },
    {
      "category" : {
        "coding" : [
          {
            "system" : "http://terminology.hl7.org/CodeSystem/adjudication",
            "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"
    }
  }
}