Benefit Program Client System API Layer | ClaimResponse-Scen1b

<ClaimResponse xmlns="http://hl7.org/fhir">
    <!--     On a create, no id will be provided.  One is included here for publishing reasons only     -->
    <id value="example-ClaimResponse-Scen1b" />
    <status value="draft" />
    <type>
        <coding>
            <system value="http://terminology.hl7.org/CodeSystem/claim-type" />
            <code value="pharmacy" />
        </coding>
    </type>
    <use value="claim" />
    <patient>
        <extension url="https://bpcs.exchange/fhir/StructureDefinition/ext-Resource-Subject">
            <valueReference>
                <reference value="Group/RB497867223" />
            </valueReference>
        </extension>
        <display value="Family RB497867223" />
    </patient>
    <created value="2024-05-02" />
    <!--  Current date  -->
    <insurer>
        <reference value="Organization/bpcs" />
    </insurer>
    <outcome value="queued" />
    <item>
        <extension url="https://bpcs.exchange/fhir/StructureDefinition/ext-Resource-ReceiptPlan">
            <valueCoding>
                <system value="https://bpcs.exchange/fhir/CodeSystem/cs-ProgramPlan" />
                <code value="T" />
            </valueCoding>
        </extension>
        <!--     <extension url="https://bpcs.exchange/fhir/StructureDefinition/ext-ClaimResponse-PresetModifier">
      <valueCoding>
        <system value="https://bpcs.exchange/fhir/CodeSystem/cs-ClaimModifier"/>
        <code value="MQ"/>
      </valueCoding>
    </extension> -->
        <!--  This will mirror the Claim.item.sequence for the receipt being responded to  -->
        <itemSequence value="1" />
        <reviewOutcome>
            <!--       <extension url="https://bpcs.exchange/fhir/StructureDefinition/ext-ClaimResponse-Info">
        <valueCodeableConcept>
          <coding>
            <system value="https://bpcs.exchange/fhir/CodeSystem/cs-ClaimResponseInfo"/>
            <code value="NOSUB"/>
          </coding>
        </valueCodeableConcept>
      </extension> -->
            <decision>
                <coding>
                    <system value="http://hl7.org/fhir/claim-decision" />
                    <code value="denied" />
                    <!--  currentStatus -->
                </coding>
            </decision>
            <reason>
                <coding>
                    <system value="https://bpcs.exchange/fhir/CodeSystem/cs-ClaimResponse" />
                    <code value="E1.3" />
                </coding>
            </reason>
            <!--       <reason>
        <extension url="https://bpcs.exchange/fhir/StructureDefinition/ext-ClaimResponse-AllowedModifier">
          <valueCoding>
            <extension url="https://bpcs.exchange/fhir/StructureDefinition/ext-ClaimResponse-PreExistingCondition">
              <valueBoolean value="true"/>
            </extension>
            <extension url="https://bpcs.exchange/fhir/StructureDefinition/ext-ClaimResponse-AllowedModifierDefault">
              <valueBoolean value="true"/>
            </extension>
            <system value="https://bpcs.exchange/fhir/CodeSystem/cs-MedicalReason"/>
            <code value="483"/>
          </valueCoding>
        </extension>
        <extension url="https://bpcs.exchange/fhir/StructureDefinition/ext-ClaimResponse-AllowedModifier">
          <valueCoding>
            <extension url="https://bpcs.exchange/fhir/StructureDefinition/ext-ClaimResponse-PreExistingCondition">
              <valueBoolean value="true"/>
            </extension>
            <system value="https://bpcs.exchange/fhir/CodeSystem/cs-MedicalReason"/>
            <code value="482"/>
          </valueCoding>
        </extension>
        <extension url="https://bpcs.exchange/fhir/StructureDefinition/ext-ClaimResponse-AllowedModifier">
          <valueCoding>
            <system value="https://bpcs.exchange/fhir/CodeSystem/cs-MedicalReason"/>
            <code value="484"/>
          </valueCoding>
        </extension>
        <extension url="https://bpcs.exchange/fhir/StructureDefinition/ext-ClaimResponse-AllowedModifier">
          <valueCoding>
            <system value="https://bpcs.exchange/fhir/CodeSystem/cs-MedicalReason"/>
            <code value="979"/>
          </valueCoding>
        </extension>
        <coding>
          <system value="https://bpcs.exchange/fhir/CodeSystem/cs-ClaimResponse"/>
          <code value="MI"/>
        </coding>
      </reason> -->
        </reviewOutcome>
        <adjudication>
            <category>
                <coding>
                    <system value="http://terminology.hl7.org/CodeSystem/adjudication" />
                    <code value="eligible" />
                </coding>
            </category>
            <amount>
                <value value="0" />
                <currency value="CAD" />
            </amount>
        </adjudication>
        <adjudication>
            <category>
                <coding>
                    <system value="http://terminology.hl7.org/CodeSystem/adjudication" />
                    <code value="benefit" />
                </coding>
            </category>
            <amount>
                <value value="0" />
                <currency value="CAD" />
            </amount>
        </adjudication>
    </item>
    <item>
        <extension url="https://bpcs.exchange/fhir/StructureDefinition/ext-Resource-ReceiptPlan">
            <valueCoding>
                <system value="https://bpcs.exchange/fhir/CodeSystem/cs-ProgramPlan" />
                <code value="T" />
            </valueCoding>
        </extension>
        <!--     <extension url="https://bpcs.exchange/fhir/StructureDefinition/ext-ClaimResponse-PresetModifier">
      <valueCoding>
        <system value="https://bpcs.exchange/fhir/CodeSystem/cs-ClaimModifier"/>
        <code value="MQ"/>
      </valueCoding>
    </extension> -->
        <!--  This will mirror the Claim.item.sequence for the receipt being responded to  -->
        <itemSequence value="2" />
        <reviewOutcome>
            <!--       <extension url="https://bpcs.exchange/fhir/StructureDefinition/ext-ClaimResponse-Info">
        <valueCodeableConcept>
          <coding>
            <system value="https://bpcs.exchange/fhir/CodeSystem/cs-ClaimResponseInfo"/>
            <code value="NOSUB"/>
          </coding>
        </valueCodeableConcept>
      </extension> -->
            <decision>
                <coding>
                    <system value="http://hl7.org/fhir/claim-decision" />
                    <code value="denied" />
                    <!--  currentStatus -->
                </coding>
            </decision>
            <reason>
                <coding>
                    <system value="https://bpcs.exchange/fhir/CodeSystem/cs-ClaimResponse" />
                    <code value="E1.3" />
                </coding>
            </reason>
            <!--       <reason>
        <extension url="https://bpcs.exchange/fhir/StructureDefinition/ext-ClaimResponse-AllowedModifier">
          <valueCoding>
            <extension url="https://bpcs.exchange/fhir/StructureDefinition/ext-ClaimResponse-PreExistingCondition">
              <valueBoolean value="true"/>
            </extension>
            <extension url="https://bpcs.exchange/fhir/StructureDefinition/ext-ClaimResponse-AllowedModifierDefault">
              <valueBoolean value="true"/>
            </extension>
            <system value="https://bpcs.exchange/fhir/CodeSystem/cs-MedicalReason"/>
            <code value="483"/>
          </valueCoding>
        </extension>
        <extension url="https://bpcs.exchange/fhir/StructureDefinition/ext-ClaimResponse-AllowedModifier">
          <valueCoding>
            <extension url="https://bpcs.exchange/fhir/StructureDefinition/ext-ClaimResponse-PreExistingCondition">
              <valueBoolean value="true"/>
            </extension>
            <system value="https://bpcs.exchange/fhir/CodeSystem/cs-MedicalReason"/>
            <code value="482"/>
          </valueCoding>
        </extension>
        <extension url="https://bpcs.exchange/fhir/StructureDefinition/ext-ClaimResponse-AllowedModifier">
          <valueCoding>
            <system value="https://bpcs.exchange/fhir/CodeSystem/cs-MedicalReason"/>
            <code value="484"/>
          </valueCoding>
        </extension>
        <extension url="https://bpcs.exchange/fhir/StructureDefinition/ext-ClaimResponse-AllowedModifier">
          <valueCoding>
            <system value="https://bpcs.exchange/fhir/CodeSystem/cs-MedicalReason"/>
            <code value="979"/>
          </valueCoding>
        </extension>
        <coding>
          <system value="https://bpcs.exchange/fhir/CodeSystem/cs-ClaimResponse"/>
          <code value="MI"/>
        </coding>
      </reason> -->
        </reviewOutcome>
        <adjudication>
            <category>
                <coding>
                    <system value="http://terminology.hl7.org/CodeSystem/adjudication" />
                    <code value="eligible" />
                </coding>
            </category>
            <amount>
                <value value="0" />
                <currency value="CAD" />
            </amount>
        </adjudication>
        <adjudication>
            <category>
                <coding>
                    <system value="http://terminology.hl7.org/CodeSystem/adjudication" />
                    <code value="benefit" />
                </coding>
            </category>
            <amount>
                <value value="0" />
                <currency value="CAD" />
            </amount>
        </adjudication>
    </item>
    <!-- 
  <responseCodes>
    <string>E2</string>
  </responseCodes>
  <updatedReceiptDto>
    <medCond></medCond> (reason for use code)
    <programId>TR</programId>
    <paymentStatus>U</paymentStatus>
    <planCode>T</planCode>
    <responseCds reference="../../responseCodes"/>
    <others/>
  </updatedReceiptDto>
 -->
</ClaimResponse>
Confirmation

ClaimResponse-Scen1b

About

Information

Follow us

Links
