FHIR IG analytics| Package | hie-fhir-ig-profile |
| Resource Type | ClaimResponse |
| Id | ClaimResponse-HIEClaimResponse-example.json |
| FHIR Version | R4B |
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Note: links and images are rebased to the (stated) source
ClaimResponse Summary
Outcome complete. Primary coverage approved with member copay. Payment issued.
| Header | Value |
|---|---|
| Status | active |
| Use | claim |
| Outcome | complete |
| Patient | Jane Patient |
| Insurer | Acme Health Insurance |
| Request | Claim/claim-001 |
| Created | 2025-11-15 |
Item Adjudication
| ItemSeq | Category | Reason | Amount |
|---|---|---|---|
| 1 | eligible | 100.00 USD | |
| 1 | copay | 20.00 USD | |
| 1 | benefit | 80.00 USD |
Totals
Payment
Notes
FHIR
FHIRsmith{
"resourceType": "ClaimResponse",
"id": "HIEClaimResponse-example",
"meta": {
"profile": [
"https://nshr.dha.go.ke/fhir/StructureDefinition/claimresponse"
]
},
"text": {
"status": "generated",
"div": "<!-- snip (see above) -->"
},
"identifier": [
{
"use": "official",
"type": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/v2-0203",
"code": "ACSN",
"display": "Accession ID"
}
]
},
"system": "http://payer.example.org/claimresponses",
"value": "CR-2025-0001"
}
],
"status": "active",
"type": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/claim-type",
"code": "professional",
"display": "Professional"
}
]
},
"use": "claim",
"patient": {
"reference": "Patient/p-001",
"display": "Jane Patient"
},
"created": "2025-11-15",
"insurer": {
"reference": "Organization/ins-001",
"display": "Acme Health Insurance"
},
"requestor": {
"reference": "Organization/org-001",
"display": "Acme Health Center"
},
"request": {
"reference": "Claim/claim-001",
"display": "OP consult claim"
},
"outcome": "complete",
"disposition": "Approved per plan rules. Member copay applied.",
"preAuthRef": "PA-556677",
"item": [
{
"itemSequence": 1,
"adjudication": [
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "eligible",
"display": "Eligible"
}
]
},
"amount": {
"value": 100,
"currency": "USD"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "copay",
"display": "Copay"
}
]
},
"amount": {
"value": 20,
"currency": "USD"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "benefit",
"display": "Benefit amount"
}
]
},
"amount": {
"value": 80,
"currency": "USD"
}
}
],
"detail": [
{
"detailSequence": 1,
"adjudication": [
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "eligible",
"display": "Eligible"
}
]
},
"amount": {
"value": 100,
"currency": "USD"
}
}
],
"subDetail": [
{
"subDetailSequence": 1,
"adjudication": [
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "benefit",
"display": "Benefit amount"
}
]
},
"amount": {
"value": 80,
"currency": "USD"
}
}
]
}
]
}
]
}
],
"addItem": [
{
"productOrService": {
"coding": [
{
"system": "http://example.org/codes/payer-adjustment",
"code": "ADJ001",
"display": "Administrative adjustment"
}
]
},
"adjudication": [
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "eligible",
"display": "Eligible"
}
]
},
"amount": {
"value": 0,
"currency": "USD"
}
}
]
}
],
"total": [
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "submitted",
"display": "Submitted Amount"
}
]
},
"amount": {
"value": 100,
"currency": "USD"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "copay",
"display": "Copay"
}
]
},
"amount": {
"value": 20,
"currency": "USD"
}
},
{
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
"code": "benefit",
"display": "Benefit Amount"
}
]
},
"amount": {
"value": 80,
"currency": "USD"
}
}
],
"payment": {
"type": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/ex-paymenttype",
"code": "payment",
"display": "Payment"
}
]
},
"date": "2025-11-16",
"amount": {
"value": 80,
"currency": "USD"
},
"identifier": {
"system": "http://payer.example.org/erds",
"value": "EPI-778899"
}
},
"processNote": [
{
"number": 1,
"type": "display",
"text": "Approved per plan. Member copay applied.",
"language": {
"coding": [
{
"system": "urn:ietf:bcp:47",
"code": "en",
"display": "English"
}
]
}
}
],
"insurance": [
{
"sequence": 1,
"focal": true,
"coverage": {
"reference": "Coverage/cov-001",
"display": "Primary PPO coverage"
}
}
]
}