FHIR Implementation Guide for HCX
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: HCX Claim Response example - XML Representation

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<ClaimResponse xmlns="http://hl7.org/fhir">
  <id value="example-01"/>
  <meta>
    <versionId value="1"/>
    <lastUpdated value="2020-07-03T22:50:39.698+00:00"/>
    <source value="#JrkobxCRdZUI6QNh"/>
  </meta>
  <text>
    <status value="generated"/>
    <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 &quot;example-01&quot; Version &quot;1&quot; Updated &quot;2020-07-03 22:50:39+0000&quot; </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/5.0.0/CodeSystem-claim-type.html">Claim Type Codes</a>#institutional)</span></p><p><b>use</b>: preauthorization</p><p><b>patient</b>: <span/></p><p><b>created</b>: 2020-07-03 18:50:39-0400</p><p><b>insurer</b>: <span/></p><p><b>requestor</b>: <span/></p><p><b>request</b>: <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/5.0.0/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/5.0.0/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/5.0.0/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/5.0.0/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/5.0.0/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/5.0.0/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/5.0.0/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/5.0.0/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>
  </text>
  <identifier>
    <system value="https://www.tmh.in/claim-response"/>
    <value value="dc82673b-8c71-48c2-2k9s-16dcb3b829m2"/>
  </identifier>
  <status value="active"/>
  <type>
    <coding>
      <system value="http://terminology.hl7.org/CodeSystem/claim-type"/>
      <code value="institutional"/>
    </coding>
  </type>
  <use value="preauthorization"/>
  <patient id="RVH1003">
    <identifier>
      <type>
        <coding>
          <system value="http://terminology.hl7.org/CodeSystem/v2-0203"/>
          <code value="SN"/>
          <display value="Subscriber Number"/>
        </coding>
      </type>
      <system value="http://gicofIndia.com/beneficiaries"/>
      <value value="BEN-101"/>
    </identifier>
  </patient>
  <created value="2020-07-03T18:50:39-04:00"/>
  <insurer id="GICOFINDIA">
    <identifier>
      <system value="http://irdai.gov.in/insurers"/>
      <value value="112"/>
    </identifier>
  </insurer>
  <requestor id="Tmh01">
    <identifier>
      <system value="http://abdm.gov.in/facilities"/>
      <value value="HFR-ID-FOR-TMH"/>
    </identifier>
  </requestor>
  <request id="example-01">
    <identifier>
      <system value="https://www.tmh.in/claim-request"/>
      <value value="dc82673b-8c71-29js-8a17-16dj3i20352n"/>
    </identifier>
  </request>
  <outcome value="complete"/>
  <item>
    <itemSequence value="1"/>
    <adjudication>
      <category>
        <coding>
          <system value="http://terminology.hl7.org/CodeSystem/adjudication"/>
          <code value="eligible"/>
        </coding>
      </category>
      <amount>
        <value value="500000"/>
        <currency value="INR"/>
      </amount>
    </adjudication>
    <adjudication>
      <category>
        <coding>
          <system value="http://terminology.hl7.org/CodeSystem/adjudication"/>
          <code value="copay"/>
        </coding>
      </category>
      <amount>
        <value value="50000"/>
        <currency value="INR"/>
      </amount>
    </adjudication>
    <adjudication>
      <category>
        <coding>
          <system value="http://terminology.hl7.org/CodeSystem/adjudication"/>
          <code value="eligpercent"/>
        </coding>
      </category>
      <value value="80.00"/>
    </adjudication>
    <adjudication>
      <category>
        <coding>
          <system value="http://terminology.hl7.org/CodeSystem/adjudication"/>
          <code value="benefit"/>
        </coding>
      </category>
      <reason>
        <coding>
          <system
                  value="http://terminology.hl7.org/CodeSystem/adjudication-reason"/>
          <code value="ar002"/>
          <display value="Plan Limit Reached"/>
        </coding>
      </reason>
      <amount>
        <value value="360000"/>
        <currency value="INR"/>
      </amount>
    </adjudication>
  </item>
  <total>
    <category>
      <coding>
        <system value="http://terminology.hl7.org/CodeSystem/adjudication"/>
        <code value="submitted"/>
      </coding>
    </category>
    <amount>
      <value value="500000"/>
      <currency value="INR"/>
    </amount>
  </total>
  <total>
    <category>
      <coding>
        <system value="http://terminology.hl7.org/CodeSystem/adjudication"/>
        <code value="benefit"/>
      </coding>
    </category>
    <amount>
      <value value="360000"/>
      <currency value="INR"/>
    </amount>
  </total>
  <payment>
    <type>
      <coding>
        <system value="http://terminology.hl7.org/CodeSystem/ex-paymenttype"/>
        <code value="complete"/>
      </coding>
    </type>
    <date value="2014-08-31"/>
    <amount>
      <value value="410000"/>
      <currency value="INR"/>
    </amount>
    <identifier>
      <system value="http://www.BenefitsInc.com/fhir/paymentidentifier"/>
      <value value="201408-2-1569478"/>
    </identifier>
  </payment>
</ClaimResponse>