FHIR Implementation Guide for ABDM
6.5.0 - active
FHIR Implementation Guide for ABDM
6.5.0 - active
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
{
"resourceType" : "ClaimResponse",
"id" : "ClaimResponse-predetermination-example-01",
"meta" : {
"profile" : [
🔗 "https://nrces.in/ndhm/fhir/r4/StructureDefinition/ClaimResponse"
]
},
"text" : {
"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p class=\"res-header-id\"><b>Generated Narrative: ClaimResponse ClaimResponse-predetermination-example-01</b></p><a name=\"ClaimResponse-predetermination-example-01\"> </a><a name=\"hcClaimResponse-predetermination-example-01\"> </a><a name=\"ClaimResponse-predetermination-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>: Predetermination</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-predetermination-example-01.html\">Claim: identifier = 7612345; status = active; type = Inpatient care management (procedure); subType = Emergency Claim; use = predetermination; billablePeriod = 2025-03-07 11:01:00+0500 --> 2025-04-07 11:01:00+0500; created = 2025-03-07 11:01:00+0500; priority = Normal</a></p><p><b>outcome</b>: Processing Complete</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>40000</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>40000</td><td>Indian rupee</td></tr></table></blockquote></blockquote><blockquote><p><b>item</b></p><p><b>itemSequence</b>: 3</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>20000</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>20000</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>70000</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>70000</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 = (?) --> 2026-03-17</a></td></tr></table></div>"
},
"status" : "active",
"type" : {
"coding" : [
{
"system" : "http://snomed.info/sct",
"code" : "737481003",
"display" : "Inpatient care management (procedure)"
}
]
},
"use" : "predetermination",
"patient" : {
🔗 "reference" : "Patient/example-01"
},
"created" : "2023-12-12T15:32:26.605+05:30",
"insurer" : {
🔗 "reference" : "Organization/example-02"
},
"requestor" : {
🔗 "reference" : "Organization/example-03"
},
"request" : {
🔗 "reference" : "Claim/Claim-predetermination-example-01"
},
"outcome" : "complete",
"preAuthRef" : "123456",
"payeeType" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/payeetype",
"code" : "provider"
}
]
},
"item" : [
{
"itemSequence" : 1,
"adjudication" : [
{
"category" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/adjudication",
"code" : "submitted",
"display" : "Submitted Amount"
}
]
},
"amount" : {
"value" : 10000,
"currency" : "INR"
}
},
{
"category" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/adjudication",
"code" : "eligpercent",
"display" : "Eligible %"
}
]
},
"reason" : {
"coding" : [
{
"system" : "https://nrces.in/ndhm/fhir/r4/CodeSystem/ndhm-adjudication-reason",
"code" : "covered",
"display" : "Product or Service requested is covered by the policy."
}
]
},
"amount" : {
"value" : 10000,
"currency" : "INR"
}
}
]
},
{
"itemSequence" : 2,
"adjudication" : [
{
"category" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/adjudication",
"code" : "submitted",
"display" : "Submitted Amount"
}
]
},
"amount" : {
"value" : 40000,
"currency" : "INR"
}
},
{
"category" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/adjudication",
"code" : "eligpercent",
"display" : "Eligible %"
}
]
},
"reason" : {
"coding" : [
{
"system" : "https://nrces.in/ndhm/fhir/r4/CodeSystem/ndhm-adjudication-reason",
"code" : "covered",
"display" : "Product or Service requested is covered by the policy."
}
]
},
"amount" : {
"value" : 40000,
"currency" : "INR"
}
}
]
},
{
"itemSequence" : 3,
"adjudication" : [
{
"category" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/adjudication",
"code" : "submitted",
"display" : "Submitted Amount"
}
]
},
"amount" : {
"value" : 20000,
"currency" : "INR"
}
},
{
"category" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/adjudication",
"code" : "eligpercent",
"display" : "Eligible %"
}
]
},
"reason" : {
"coding" : [
{
"system" : "https://nrces.in/ndhm/fhir/r4/CodeSystem/ndhm-adjudication-reason",
"code" : "covered",
"display" : "Product or Service requested is covered by the policy."
}
]
},
"amount" : {
"value" : 20000,
"currency" : "INR"
}
}
]
}
],
"total" : [
{
"category" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/adjudication",
"code" : "submitted",
"display" : "Submitted Amount"
}
]
},
"amount" : {
"value" : 70000,
"currency" : "INR"
}
},
{
"category" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/adjudication",
"code" : "eligpercent",
"display" : "Eligible %"
}
]
},
"amount" : {
"value" : 70000,
"currency" : "INR"
}
}
],
"insurance" : [
{
"sequence" : 1,
"focal" : true,
"coverage" : {
🔗 "reference" : "Coverage/example-01"
}
}
]
}