81-Adjudication Details Response

Parameters
<Parameters xmlns="http://hl7.org/fhir">
<id value="adjudication-details-out-sample" />
<parameter>
<name value="TraceNumber" />
<valueIdentifier>
<value value="9876543210" />
</valueIdentifier>
</parameter>
<parameter>
<name value="ReferenceNumber" />
<valueIdentifier>
<value value="RFN-20251111-001" />
</valueIdentifier>
</parameter>
<parameter>
<name value="ResponseStatus" />
<valueCode value="Z" />
</parameter>
<parameter>
<name value="ResponseCodes" />
<valueCode value="0000" />
</parameter>
<parameter>
<name value="TimePeriod" />
<valuePeriod>
<start value="2025-11-01" />
<end value="2025-11-30" />
</valuePeriod>
</parameter>
<parameter>
<name value="TotalAmtForPeriod" />
<valueMoney>
<value value="75.00" />
<currency value="CAD" />
</valueMoney>
</parameter>
<parameter>
<name value="ReversalTotalAmtForPeriod" />
<valueMoney>
<value value="25.00" />
<currency value="CAD" />
</valueMoney>
</parameter>
<parameter>
<name value="ClaimTotalAmtForPeriod" />
<valueMoney>
<value value="100.00" />
<currency value="CAD" />
</valueMoney>
</parameter>
<parameter>
<name value="AdjudicationDate" />
<valueDateTime value="2025-11-10T14:30:00-05:00" />
<part>
<name value="CurrentRXNumber" />
<valueIdentifier>
<value value="1234567890" />
</valueIdentifier>
</part>
<part>
<name value="TraceNumber" />
<valueIdentifier>
<value value="0011223344" />
</valueIdentifier>
</part>
<part>
<name value="AmountPayable/ReversedPatient" />
<valueMoney>
<value value="0.00" />
<currency value="CAD" />
</valueMoney>
</part>
<part>
<name value="AmountPayable/ReversedPharmacy" />
<valueMoney>
<value value="100.00" />
<currency value="CAD" />
</valueMoney>
</part>
<part>
<name value="CarrierID" />
<valueIdentifier>
<value value="CARRIER-A" />
</valueIdentifier>
</part>
<part>
<name value="CurrentRXNumber" />
<valueIdentifier>
<value value="0987654321" />
</valueIdentifier>
</part>
<part>
<name value="TraceNumber" />
<valueIdentifier>
<value value="5566778899" />
</valueIdentifier>
</part>
<part>
<name value="AmountPayable/ReversedPatient" />
<valueMoney>
<value value="-25.00" />
<currency value="CAD" />
</valueMoney>
</part>
<part>
<name value="AmountPayable/ReversedPharmacy" />
<valueMoney>
<value value="0.00" />
<currency value="CAD" />
</valueMoney>
</part>
<part>
<name value="CarrierID" />
<valueIdentifier>
<value value="CARRIER-B" />
</valueIdentifier>
</part>
</parameter>
</Parameters>
{
"resourceType": "Parameters",
"id": "adjudication-details-out-sample",
"parameter": [
{
"name": "TraceNumber",
"valueIdentifier": {
"value": "9876543210"
}
},
{
"name": "ReferenceNumber",
"valueIdentifier": {
"value": "RFN-20251111-001"
}
},
{
"name": "ResponseStatus",
"valueCode": "Z"
},
{
"name": "ResponseCodes",
"valueCode": "0000"
},
{
"name": "TimePeriod",
"valuePeriod": {
"start": "2025-11-01",
"end": "2025-11-30"
}
},
{
"name": "TotalAmtForPeriod",
"valueMoney": {
"value": 75,
"currency": "CAD"
}
},
{
"name": "ReversalTotalAmtForPeriod",
"valueMoney": {
"value": 25,
"currency": "CAD"
}
},
{
"name": "ClaimTotalAmtForPeriod",
"valueMoney": {
"value": 100,
"currency": "CAD"
}
},
{
"name": "AdjudicationDate",
"valueDateTime": "2025-11-10T14:30:00-05:00",
"part": [
{
"name": "CurrentRXNumber",
"valueIdentifier": {
"value": "1234567890"
}
},
{
"name": "TraceNumber",
"valueIdentifier": {
"value": "0011223344"
}
},
{
"name": "AmountPayable/ReversedPatient",
"valueMoney": {
"value": 0,
"currency": "CAD"
}
},
{
"name": "AmountPayable/ReversedPharmacy",
"valueMoney": {
"value": 100,
"currency": "CAD"
}
},
{
"name": "CarrierID",
"valueIdentifier": {
"value": "CARRIER-A"
}
},
{
"name": "CurrentRXNumber",
"valueIdentifier": {
"value": "0987654321"
}
},
{
"name": "TraceNumber",
"valueIdentifier": {
"value": "5566778899"
}
},
{
"name": "AmountPayable/ReversedPatient",
"valueMoney": {
"value": -25,
"currency": "CAD"
}
},
{
"name": "AmountPayable/ReversedPharmacy",
"valueMoney": {
"value": 0,
"currency": "CAD"
}
},
{
"name": "CarrierID",
"valueIdentifier": {
"value": "CARRIER-B"
}
}
]
}
]
}