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Source1

{
  "resourceType": "ClaimResponse",
  "id": "primary-coverage",
  "meta": {
    "profile": [
      "http://fhir.health.gov.il/StructureDefinition/il-core-claim-response"
    ]
  },
  "identifier": [
    {
      "system": "http://www.BenefitsInc.com/fhir/remittance",
      "value": "R3500"
    }
  ],
  "status": "active",
  "type": {
    "coding": [
      {
        "code": "oral",
        "system": "http://terminology.hl7.org/CodeSystem/claim-type"
      }
    ]
  },
  "subType": {
    "coding": [
      {
        "code": "emergency",
        "system": "http://terminology.hl7.org/CodeSystem/ex-claimsubtype"
      }
    ]
  },
  "use": "claim",
  "patient": {
    "reference": "Patient/patient-israeli"
  },
  "created": "2014-08-16",
  "insurer": {
    "identifier": {
      "system": "http://www.jurisdiction.org/insurers",
      "value": "555123"
    }
  },
  "requestor": {
    "reference": "Organization/ministry-of-health"
  },
  "outcome": "complete",
  "disposition": "Claim settled as per contract.",
  "payeeType": {
    "coding": [
      {
        "code": "provider",
        "system": "http://terminology.hl7.org/CodeSystem/payeetype"
      }
    ]
  },
  "item": [
    {
      "itemSequence": 1,
      "adjudication": [
        {
          "category": {
            "coding": [
              {
                "code": "eligible"
              }
            ]
          },
          "amount": {
            "value": 135.57,
            "currency": "USD"
          }
        },
        {
          "category": {
            "coding": [
              {
                "code": "copay"
              }
            ]
          },
          "amount": {
            "value": 10,
            "currency": "USD"
          }
        },
        {
          "category": {
            "coding": [
              {
                "code": "eligpercent"
              }
            ]
          },
          "value": 80
        },
        {
          "category": {
            "coding": [
              {
                "code": "benefit"
              }
            ]
          },
          "reason": {
            "coding": [
              {
                "code": "ar002",
                "system": "http://terminology.hl7.org/CodeSystem/adjudication-reason",
                "display": "Plan Limit Reached"
              }
            ]
          },
          "amount": {
            "value": 90.47,
            "currency": "USD"
          }
        }
      ]
    }
  ],
  "total": [
    {
      "category": {
        "coding": [
          {
            "code": "submitted"
          }
        ]
      },
      "amount": {
        "value": 135.57,
        "currency": "USD"
      }
    },
    {
      "category": {
        "coding": [
          {
            "code": "benefit"
          }
        ]
      },
      "amount": {
        "value": 90.47,
        "currency": "USD"
      }
    }
  ],
  "payment": {
    "type": {
      "coding": [
        {
          "code": "complete",
          "system": "http://terminology.hl7.org/CodeSystem/ex-paymenttype"
        }
      ]
    },
    "date": "2014-08-31",
    "amount": {
      "value": 100.47,
      "currency": "USD"
    },
    "identifier": {
      "system": "http://www.BenefitsInc.com/fhir/paymentidentifier",
      "value": "201408-2-1569478"
    },
    "adjustment": {
      "value": -5,
      "currency": "USD"
    },
    "adjustmentReason": {
      "coding": [
        {
          "code": "ar005",
          "system": "http://terminology.hl7.org/CodeSystem/adjudication-reason",
          "display": "Contractual adjustment"
        }
      ]
    }
  },
  "request": {
    "reference": "Claim/dental-claim"
  }
}