This page is part of the FHIR Implementation Guide for ABDM (v6.5.0: Release) based on FHIR (HL7® FHIR® Standard) R4. This is the current published version. For a full list of available versions, see the Directory of published versions

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: ClaimResponse/ClaimResponse-enhancement-example-01 - XML Representation

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<ClaimResponse xmlns="http://hl7.org/fhir">
  <id value="ClaimResponse-enhancement-example-01"/>
  <meta>
    <profile
             value="https://nrces.in/ndhm/fhir/r4/StructureDefinition/ClaimResponse"/>
  </meta>
  <text>
    <status value="generated"/>
    <div xmlns="http://www.w3.org/1999/xhtml"><p class="res-header-id"><b>Generated Narrative: ClaimResponse ClaimResponse-enhancement-example-01</b></p><a name="ClaimResponse-enhancement-example-01"> </a><a name="hcClaimResponse-enhancement-example-01"> </a><a name="ClaimResponse-enhancement-example-01-hi-IN"> </a><p><b>status</b>: Active</p><p><b>type</b>: <span title="Codes:{http://snomed.info/sct 737481003}">Inpatient care management (procedure)</span></p><p><b>use</b>: Preauthorization</p><p><b>patient</b>: <a href="Patient-example-01.html">ABC Male, DoB: 1981-01-12 ( Medical record number: 22-7225-4829-5255)</a></p><p><b>created</b>: 2023-12-12 15:32:26+0530</p><p><b>insurer</b>: <a href="Organization-example-02.html">Organization XYZ Insurance Co. Ltd.</a></p><p><b>requestor</b>: <a href="Organization-example-03.html">Organization XYZ Hospital Co. Ltd.</a></p><p><b>request</b>: <a href="Claim-Claim-enhancement-example-01.html">Claim: identifier = 7612345; status = active; type = Inpatient care management (procedure); subType = Emergency Claim; use = preauthorization; billablePeriod = 2025-03-07 11:01:00+0500 --&gt; 2025-04-07 11:01:00+0500; created = 2025-03-13 11:01:00+0500; priority = Normal</a></p><p><b>outcome</b>: Processing Complete</p><p><b>disposition</b>: The enclosed services are authorized for your provision within 30 days of this notice.</p><p><b>preAuthRef</b>: 123456</p><p><b>payeeType</b>: <span title="Codes:{http://terminology.hl7.org/CodeSystem/payeetype provider}">Provider</span></p><blockquote><p><b>item</b></p><p><b>itemSequence</b>: 1</p><blockquote><p><b>adjudication</b></p><p><b>category</b>: <span title="Codes:{http://terminology.hl7.org/CodeSystem/adjudication submitted}">Submitted Amount</span></p><h3>Amounts</h3><table class="grid"><tr><td style="display: none">-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td style="display: none">*</td><td>10000</td><td>Indian rupee</td></tr></table></blockquote><blockquote><p><b>adjudication</b></p><p><b>category</b>: <span title="Codes:{http://terminology.hl7.org/CodeSystem/adjudication eligpercent}">Eligible %</span></p><p><b>reason</b>: <span title="Codes:{https://nrces.in/ndhm/fhir/r4/CodeSystem/ndhm-adjudication-reason covered}">Product or Service requested is covered by the policy.</span></p><h3>Amounts</h3><table class="grid"><tr><td style="display: none">-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td style="display: none">*</td><td>10000</td><td>Indian rupee</td></tr></table></blockquote></blockquote><blockquote><p><b>item</b></p><p><b>itemSequence</b>: 2</p><blockquote><p><b>adjudication</b></p><p><b>category</b>: <span title="Codes:{http://terminology.hl7.org/CodeSystem/adjudication submitted}">Submitted Amount</span></p><h3>Amounts</h3><table class="grid"><tr><td style="display: none">-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td style="display: none">*</td><td>10000</td><td>Indian rupee</td></tr></table></blockquote><blockquote><p><b>adjudication</b></p><p><b>category</b>: <span title="Codes:{http://terminology.hl7.org/CodeSystem/adjudication eligpercent}">Eligible %</span></p><p><b>reason</b>: <span title="Codes:{https://nrces.in/ndhm/fhir/r4/CodeSystem/ndhm-adjudication-reason covered}">Product or Service requested is covered by the policy.</span></p><h3>Amounts</h3><table class="grid"><tr><td style="display: none">-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td style="display: none">*</td><td>10000</td><td>Indian rupee</td></tr></table></blockquote></blockquote><blockquote><p><b>total</b></p><p><b>category</b>: <span title="Codes:{http://terminology.hl7.org/CodeSystem/adjudication submitted}">Submitted Amount</span></p><h3>Amounts</h3><table class="grid"><tr><td style="display: none">-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td style="display: none">*</td><td>20000</td><td>Indian rupee</td></tr></table></blockquote><blockquote><p><b>total</b></p><p><b>category</b>: <span title="Codes:{http://terminology.hl7.org/CodeSystem/adjudication eligpercent}">Eligible %</span></p><h3>Amounts</h3><table class="grid"><tr><td style="display: none">-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td style="display: none">*</td><td>20000</td><td>Indian rupee</td></tr></table></blockquote><h3>Insurances</h3><table class="grid"><tr><td style="display: none">-</td><td><b>Sequence</b></td><td><b>Focal</b></td><td><b>Coverage</b></td></tr><tr><td style="display: none">*</td><td>1</td><td>true</td><td><a href="Coverage-example-01.html">Coverage: identifier = https://xyzinsurance.in/policynumber/#235037120; status = active; type = PAY; subscriberId = ABC123456BI007; relationship = Self; period = (?) --&gt; 2026-03-17</a></td></tr></table></div>
  </text>
  <status value="active"/>
  <type>
    <coding>
      <system value="http://snomed.info/sct"/>
      <code value="737481003"/>
      <display value="Inpatient care management (procedure)"/>
    </coding>
  </type>
  <use value="preauthorization"/>
  <patient>🔗 
    <reference value="Patient/example-01"/>
  </patient>
  <created value="2023-12-12T15:32:26.605+05:30"/>
  <insurer>🔗 
    <reference value="Organization/example-02"/>
  </insurer>
  <requestor>🔗 
    <reference value="Organization/example-03"/>
  </requestor>
  <request>🔗 
    <reference value="Claim/Claim-enhancement-example-01"/>
  </request>
  <outcome value="complete"/>
  <disposition
               value="The enclosed services are authorized for your provision within 30 days of this notice."/>
  <preAuthRef value="123456"/>
  <payeeType>
    <coding>
      <system value="http://terminology.hl7.org/CodeSystem/payeetype"/>
      <code value="provider"/>
    </coding>
  </payeeType>
  <item>
    <itemSequence value="1"/>
    <adjudication>
      <category>
        <coding>
          <system value="http://terminology.hl7.org/CodeSystem/adjudication"/>
          <code value="submitted"/>
          <display value="Submitted Amount"/>
        </coding>
      </category>
      <amount>
        <value value="10000"/>
        <currency value="INR"/>
      </amount>
    </adjudication>
    <adjudication>
      <category>
        <coding>
          <system value="http://terminology.hl7.org/CodeSystem/adjudication"/>
          <code value="eligpercent"/>
          <display value="Eligible %"/>
        </coding>
      </category>
      <reason>
        <coding>
          <system
                  value="https://nrces.in/ndhm/fhir/r4/CodeSystem/ndhm-adjudication-reason"/>
          <code value="covered"/>
          <display
                   value="Product or Service requested is covered by the policy."/>
        </coding>
      </reason>
      <amount>
        <value value="10000"/>
        <currency value="INR"/>
      </amount>
    </adjudication>
  </item>
  <item>
    <itemSequence value="2"/>
    <adjudication>
      <category>
        <coding>
          <system value="http://terminology.hl7.org/CodeSystem/adjudication"/>
          <code value="submitted"/>
          <display value="Submitted Amount"/>
        </coding>
      </category>
      <amount>
        <value value="10000"/>
        <currency value="INR"/>
      </amount>
    </adjudication>
    <adjudication>
      <category>
        <coding>
          <system value="http://terminology.hl7.org/CodeSystem/adjudication"/>
          <code value="eligpercent"/>
          <display value="Eligible %"/>
        </coding>
      </category>
      <reason>
        <coding>
          <system
                  value="https://nrces.in/ndhm/fhir/r4/CodeSystem/ndhm-adjudication-reason"/>
          <code value="covered"/>
          <display
                   value="Product or Service requested is covered by the policy."/>
        </coding>
      </reason>
      <amount>
        <value value="10000"/>
        <currency value="INR"/>
      </amount>
    </adjudication>
  </item>
  <total>
    <category>
      <coding>
        <system value="http://terminology.hl7.org/CodeSystem/adjudication"/>
        <code value="submitted"/>
        <display value="Submitted Amount"/>
      </coding>
    </category>
    <amount>
      <value value="20000"/>
      <currency value="INR"/>
    </amount>
  </total>
  <total>
    <category>
      <coding>
        <system value="http://terminology.hl7.org/CodeSystem/adjudication"/>
        <code value="eligpercent"/>
        <display value="Eligible %"/>
      </coding>
    </category>
    <amount>
      <value value="20000"/>
      <currency value="INR"/>
    </amount>
  </total>
  <insurance>
    <sequence value="1"/>
    <focal value="true"/>
    <coverage>🔗 
      <reference value="Coverage/example-01"/>
    </coverage>
  </insurance>
</ClaimResponse>