{"created":"2014-08-16","disposition":"Claim settled as per contract.","id":"R3502","identifier":[{"system":"http://thebenefitcompany.com/claimresponse","value":"CR6532875367"}],"insurer":{"reference":"Organization/2"},"item":[{"adjudication":[{"amount":{"currency":"USD","value":235.40},"category":{"coding":[{"code":"eligible"}]}},{"amount":{"currency":"USD","value":20.00},"category":{"coding":[{"code":"copay"}]}},{"category":{"coding":[{"code":"eligpercent"}]},"quantity":{"value":80.00}},{"amount":{"currency":"USD","value":172.32},"category":{"coding":[{"code":"benefit"}]}}],"detail":[{"adjudication":[{"amount":{"currency":"USD","value":100.00},"category":{"coding":[{"code":"eligible"}]}},{"amount":{"currency":"USD","value":20.00},"category":{"coding":[{"code":"copay"}]}},{"category":{"coding":[{"code":"eligpercent"}]},"quantity":{"value":80.00}},{"amount":{"currency":"USD","value":80.00},"category":{"coding":[{"code":"benefit"}]}}],"detailSequence":1,"noteNumber":[1]},{"adjudication":[{"amount":{"currency":"USD","value":110.00},"category":{"coding":[{"code":"eligible"}]}},{"category":{"coding":[{"code":"eligpercent"}]},"quantity":{"value":80.00}},{"amount":{"currency":"USD","value":88.00},"category":{"coding":[{"code":"benefit"}]}}],"detailSequence":2,"noteNumber":[1],"subDetail":[{"adjudication":[{"amount":{"currency":"USD","value":60.00},"category":{"coding":[{"code":"eligible"}]}},{"category":{"coding":[{"code":"eligpercent"}]},"quantity":{"value":80.00}},{"amount":{"currency":"USD","value":48.00},"category":{"coding":[{"code":"benefit"}]}}],"noteNumber":[1],"subDetailSequence":1},{"adjudication":[{"amount":{"currency":"USD","value":30.00},"category":{"coding":[{"code":"eligible"}]}},{"category":{"coding":[{"code":"eligpercent"}]},"quantity":{"value":80.00}},{"amount":{"currency":"USD","value":24.00},"category":{"coding":[{"code":"benefit"}]}}],"subDetailSequence":2},{"adjudication":[{"amount":{"currency":"USD","value":10.00},"category":{"coding":[{"code":"eligible"}]}},{"category":{"coding":[{"code":"eligpercent"}]},"quantity":{"value":80.00}},{"amount":{"currency":"USD","value":8.00},"category":{"coding":[{"code":"benefit"}]}}],"noteNumber":[1],"subDetailSequence":3}]},{"adjudication":[{"amount":{"currency":"USD","value":200.00},"category":{"coding":[{"code":"eligible"}]}},{"category":{"coding":[{"code":"eligpercent"}]},"quantity":{"value":80.00}},{"amount":{"currency":"USD","value":14.00},"category":{"coding":[{"code":"benefit"}]}}],"detailSequence":3,"noteNumber":[1]}],"itemSequence":1}],"outcome":"complete","patient":{"reference":"Patient/1"},"payeeType":{"coding":[{"code":"provider","system":"http://terminology.hl7.org/CodeSystem/payeetype"}]},"payment":{"adjustment":{"currency":"USD","value":75.00},"adjustmentReason":{"coding":[{"code":"a002","display":"Prior Overpayment","system":"http://terminology.hl7.org/CodeSystem/payment-adjustment-reason"}]},"amount":{"currency":"USD","value":107.00},"date":"2014-08-16","identifier":{"system":"http://thebenefitcompany.com/paymentidentifier","value":"201416-123456"},"type":{"coding":[{"code":"complete","system":"http://terminology.hl7.org/CodeSystem/ex-paymenttype"}]}},"processNote":[{"language":{"coding":[{"code":"en-CA","system":"urn:ietf:bcp:47"}]},"number":1,"text":"After hours surcharge declined","type":{"coding":[{"code":"display","system":"http://hl7.org/fhir/note-type"}]}}],"request":{"identifier":{"system":"http://happysight.com/claim","value":"6612346"}},"requestor":{"reference":"Organization/1"},"resourceType":"ClaimResponse","status":"active","text":{"div":"<div xmlns=\"http://www.w3.org/1999/xhtml\">A human-readable rendering of the ClaimResponse</div>","status":"generated"},"total":[{"amount":{"currency":"USD","value":235.40},"category":{"coding":[{"code":"submitted"}]}},{"amount":{"currency":"USD","value":182.00},"category":{"coding":[{"code":"benefit"}]}}],"type":{"coding":[{"code":"vision","system":"http://terminology.hl7.org/CodeSystem/claim-type"}]},"use":"claim"}