Benefit Program Client System API Layer | ClaimResponse

<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" />
    <contained>
        <MedicationDispense>
            <id value="DISP1" />
            <meta>
                <profile value="https://bpcs.exchange/fhir/StructureDefinition/profile-MedicationDispense" />
            </meta>
            <identifier>
                <value value="5" />
            </identifier>
            <status value="completed" />
            <medication>
                <concept>
                    <coding>
                        <system value="http://hl7.org/fhir/NamingSystem/ca-hc-din" />
                        <code value="23450" />
                        <display value="Dilantin-125 Suspension" />
                    </coding>
                    <coding>
                        <system value="http://terminology.hl7.org/CodeSystem/hc-CCDD" />
                        <display value="PHENYTOIN (DIPHENYLHYDANTOIN)" />
                    </coding>
                </concept>
            </medication>
            <subject>
                <reference value="Patient/example-Patient" />
                <!--  This would normally be the odbNum from the original claim  -->
            </subject>
            <whenHandedOver value="2022-06-25" />
        </MedicationDispense>
    </contained>
    <contained>
        <MedicationDispense>
            <id value="DISP2" />
            <meta>
                <profile value="https://bpcs.exchange/fhir/StructureDefinition/profile-MedicationDispense" />
            </meta>
            <identifier>
                <value value="5" />
            </identifier>
            <status value="completed" />
            <medication>
                <concept>
                    <coding>
                        <system value="http://hl7.org/fhir/NamingSystem/ca-hc-din" />
                        <code value="23450" />
                        <display value="Dilantin-125 Suspension" />
                    </coding>
                    <coding>
                        <system value="http://terminology.hl7.org/CodeSystem/hc-CCDD" />
                        <display value="PHENYTOIN (DIPHENYLHYDANTOIN)" />
                    </coding>
                </concept>
            </medication>
            <subject>
                <reference value="Patient/example-Patient" />
                <!--  This would normally be the odbNum from the original claim  -->
            </subject>
            <whenHandedOver value="2022-06-13" />
        </MedicationDispense>
    </contained>
    <contained>
        <ExplanationOfBenefit>
            <id value="dups" />
            <status value="active" />
            <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>
                        <!--  This would normally be the application number  -->
                        <reference value="Group/example-Group" />
                    </valueReference>
                </extension>
                <display value="Family RB497867223" />
            </patient>
            <created value="2023-08-16T13:27:37-04:00" />
            <insurer>
                <reference value="Organization/bpcs" />
            </insurer>
            <outcome value="complete" />
            <supportingInfo>
                <sequence value="1" />
                <category>
                    <coding>
                        <system value="http://terminology.hl7.org/CodeSystem/claiminformationcategory" />
                        <code value="info" />
                    </coding>
                </category>
                <valueReference>
                    <reference value="#DISP1" />
                </valueReference>
            </supportingInfo>
            <supportingInfo>
                <sequence value="2" />
                <category>
                    <coding>
                        <system value="http://terminology.hl7.org/CodeSystem/claiminformationcategory" />
                        <code value="info" />
                    </coding>
                </category>
                <valueReference>
                    <reference value="#DISP2" />
                </valueReference>
            </supportingInfo>
            <item>
                <!-- 
  <duplicateClaims>
    <ca.ontario.health.hns.web.dto.cm.DuplicateClaimDTO>
      <outputTotal>100.0</outputTotal>
*      <transCd>01</transCd>
*      <maxRecipReimbAmt>0.0</maxRecipReimbAmt>
*      <ovrpdlogExistFlag>false</ovrpdlogExistFlag>
*      <exactMatchFlag>false</exactMatchFlag>
    </ca.ontario.health.hns.web.dto.cm.DuplicateClaimDTO>
 -->
                <extension url="https://bpcs.exchange/fhir/StructureDefinition/ext-Claim-ReceiptPatient">
                    <valueReference>
                        <reference value="Patient/example-Patient" />
                        <!--  This will normally be the odbNum of the patient from the original claim  -->
                    </valueReference>
                </extension>
                <extension url="https://bpcs.exchange/fhir/StructureDefinition/ext-Claim-DuplicateVersion">
                    <valueUnsignedInt value="1" />
                </extension>
                <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-Resource-DeductibleStatus">
                    <valueCoding>
                        <system value="https://bpcs.exchange/fhir/CodeSystem/cs-DeductibleStatus" />
                        <code value="1" />
                    </valueCoding>
                </extension>
                <sequence value="1" />
                <informationSequence value="1" />
                <productOrService>
                    <coding>
                        <system value="http://hl7.org/fhir/NamingSystem/ca-hc-din" />
                        <code value="23450" />
                        <display value="Dilantin-125 Suspension" />
                    </coding>
                    <coding>
                        <system value="http://terminology.hl7.org/CodeSystem/hc-CCDD" />
                        <display value="PHENYTOIN (DIPHENYLHYDANTOIN)" />
                    </coding>
                </productOrService>
                <modifier>
                    <coding>
                        <system value="https://bpcs.exchange/fhir/CodeSystem/cs-MedicalReason" />
                        <code value="25" />
                    </coding>
                </modifier>
                <patientPaid>
                    <value value="999" />
                    <currency value="CAD" />
                </patientPaid>
                <reviewOutcome>
                    <decision>
                        <coding>
                            <system value="http://hl7.org/fhir/claim-decision" />
                            <code value="denied" />
                        </coding>
                    </decision>
                </reviewOutcome>
                <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>
                <adjudication>
                    <category>
                        <coding>
                            <system value="http://terminology.hl7.org/CodeSystem/adjudication" />
                            <code value="deductible" />
                        </coding>
                    </category>
                    <amount>
                        <value value="999" />
                        <currency value="CAD" />
                    </amount>
                </adjudication>
                <detail>
                    <sequence value="1" />
                    <productOrService>
                        <coding>
                            <system value="https://bpcs.exchange/fhir/CodeSystem/cs-CostFee" />
                            <code value="drugCost" />
                        </coding>
                    </productOrService>
                    <adjudication>
                        <category>
                            <coding>
                                <system value="http://terminology.hl7.org/CodeSystem/adjudication" />
                                <code value="submitted" />
                            </coding>
                        </category>
                        <amount>
                            <value value="999" />
                            <currency value="CAD" />
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value="http://terminology.hl7.org/CodeSystem/adjudication" />
                                <code value="eligible" />
                            </coding>
                        </category>
                        <amount>
                            <value value="100" />
                            <currency value="CAD" />
                        </amount>
                    </adjudication>
                </detail>
                <detail>
                    <sequence value="2" />
                    <productOrService>
                        <coding>
                            <system value="https://bpcs.exchange/fhir/CodeSystem/cs-CostFee" />
                            <code value="pharmacistFee" />
                        </coding>
                    </productOrService>
                    <adjudication>
                        <category>
                            <coding>
                                <system value="http://terminology.hl7.org/CodeSystem/adjudication" />
                                <code value="submitted" />
                            </coding>
                        </category>
                        <amount>
                            <value value="10" />
                            <currency value="CAD" />
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value="http://terminology.hl7.org/CodeSystem/adjudication" />
                                <code value="eligible" />
                            </coding>
                        </category>
                        <amount>
                            <value value="10" />
                            <currency value="CAD" />
                        </amount>
                    </adjudication>
                </detail>
            </item>
            <item>
                <extension url="https://bpcs.exchange/fhir/StructureDefinition/ext-Claim-ReceiptPatient">
                    <valueReference>
                        <reference value="Patient/example-Patient" />
                        <!--  This will normally be the odbNum of the patient from the original claim  -->
                    </valueReference>
                </extension>
                <extension url="https://bpcs.exchange/fhir/StructureDefinition/ext-Claim-DuplicateVersion">
                    <valueUnsignedInt value="1" />
                </extension>
                <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>
                <sequence value="2" />
                <informationSequence value="2" />
                <productOrService>
                    <coding>
                        <system value="http://hl7.org/fhir/NamingSystem/ca-hc-din" />
                        <code value="23450" />
                        <display value="Dilantin-125 Suspension" />
                    </coding>
                    <coding>
                        <system value="http://terminology.hl7.org/CodeSystem/hc-CCDD" />
                        <display value="PHENYTOIN (DIPHENYLHYDANTOIN)" />
                    </coding>
                </productOrService>
                <modifier>
                    <coding>
                        <system value="https://bpcs.exchange/fhir/CodeSystem/cs-MedicalReason" />
                        <code value="25" />
                    </coding>
                </modifier>
                <patientPaid>
                    <value value="999" />
                    <currency value="CAD" />
                </patientPaid>
                <reviewOutcome>
                    <decision>
                        <coding>
                            <system value="http://hl7.org/fhir/claim-decision" />
                            <code value="approved" />
                        </coding>
                    </decision>
                </reviewOutcome>
                <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>
                <adjudication>
                    <category>
                        <coding>
                            <system value="http://terminology.hl7.org/CodeSystem/adjudication" />
                            <code value="deductible" />
                        </coding>
                    </category>
                    <amount>
                        <value value="999" />
                        <currency value="CAD" />
                    </amount>
                </adjudication>
                <detail>
                    <sequence value="1" />
                    <productOrService>
                        <coding>
                            <system value="https://bpcs.exchange/fhir/CodeSystem/cs-CostFee" />
                            <code value="drugCost" />
                        </coding>
                    </productOrService>
                    <adjudication>
                        <category>
                            <coding>
                                <system value="http://terminology.hl7.org/CodeSystem/adjudication" />
                                <code value="submitted" />
                            </coding>
                        </category>
                        <amount>
                            <value value="999" />
                            <currency value="CAD" />
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value="http://terminology.hl7.org/CodeSystem/adjudication" />
                                <code value="eligible" />
                            </coding>
                        </category>
                        <amount>
                            <value value="100" />
                            <currency value="CAD" />
                        </amount>
                    </adjudication>
                </detail>
                <detail>
                    <sequence value="2" />
                    <productOrService>
                        <coding>
                            <system value="https://bpcs.exchange/fhir/CodeSystem/cs-CostFee" />
                            <code value="pharmacistFee" />
                        </coding>
                    </productOrService>
                    <adjudication>
                        <category>
                            <coding>
                                <system value="http://terminology.hl7.org/CodeSystem/adjudication" />
                                <code value="submitted" />
                            </coding>
                        </category>
                        <amount>
                            <value value="10" />
                            <currency value="CAD" />
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value="http://terminology.hl7.org/CodeSystem/adjudication" />
                                <code value="eligible" />
                            </coding>
                        </category>
                        <amount>
                            <value value="10" />
                            <currency value="CAD" />
                        </amount>
                    </adjudication>
                </detail>
            </item>
        </ExplanationOfBenefit>
    </contained>
    <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>
                <!--  This would normally be the application number  -->
                <reference value="Group/example-Group" />
            </valueReference>
        </extension>
        <display value="Family RB497867223" />
    </patient>
    <created value="2022-08-03" />
    <insurer>
        <reference value="Organization/bpcs" />
    </insurer>
    <request>
        <!--  This will echo the Claim.id as it was on the inbound request (application num or odbNum, followed by submitted date, followed by sequence)  -->
        <reference value="Claim/example-Claim-submit" />
    </request>
    <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>
                <extension url="https://bpcs.exchange/fhir/StructureDefinition/ext-ClaimResponse-DuplicateReceipts">
                    <extension url="EOB">
                        <valueReference>
                            <reference value="#dups" />
                        </valueReference>
                    </extension>
                    <extension url="receipt">
                        <valuePositiveInt value="1" />
                    </extension>
                    <extension url="receipt">
                        <valuePositiveInt value="2" />
                    </extension>
                </extension>
                <coding>
                    <system value="https://bpcs.exchange/fhir/CodeSystem/cs-ClaimResponse" />
                    <code value="EE.R" />
                </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

About

Information

Follow us

Links
