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Code Block
languagejson
{
    "resourceType": "ClaimResponse",
    "addItem": [
        {
            "itemSequence": [
                1
            ],
            "productOrService": {
                "coding": [
                    {
                        "code": "0182"
                    }
                ]
            }
        },
        {
            "itemSequence": [
                2
            ],
            "productOrService": {
                "coding": [
                    {
                        "code": "A1"
                    }
                ]
            }
        }
    ],
    "created": "2020-06-29",
    "id": "576D56EF-12D2-4BA8-9640-2A37C41A2052",
    "identifier": [
        {
            "type": {
                "coding": [
                    {
                        "code": "ACSN",
                        "system": "https://hl7.org/fhir/valueset-identifier-type.html"
                    }
                ]
            },
            "use": "usual",
            "value": "576D56EF-12D2-4BA8-9640-2A37C41A2052"
        },
        {
            "type": {
                "coding": [
                    {
                        "code": "MR",
                        "system": "https://hl7.org/fhir/valueset-identifier-type.html"
                    }
                ]
            },
            "use": "usual",
            "value": "JADH0001"
        }
    ],
    "item": [
        {
            "adjudication": [
                {
                    "amount": {
                        "value": 10.0
                    },
                    "category": {
                        "text": "general"
                    },
                    "reason": {
                        "coding": [
                            {
                                "code": "1"
                            }
                        ],
                        "text": "passed"
                    }
                }
            ],
            "itemSequence": 1
        },
        {
            "adjudication": [
                {
                    "amount": {
                        "value": 400.0
                    },
                    "category": {
                        "text": "general"
                    },
                    "reason": {
                        "coding": [
                            {
                                "code": "1"
                            }
                        ],
                        "text": "passed"
                    }
                }
            ],
            "itemSequence": 2
        }
    ],
    "outcome": {
        "coding": [
            {
                "code": "16"
            }
        ],
        "text": "valuated"
    },
    "patient": {
        "reference": "Claim/8C90949B-D1E5-47C8-A2D7-D5ECD073F1EE"
    },
    "request": {
        "reference": "Claim/576D56EF-12D2-4BA8-9640-2A37C41A2052"
    },
    "total": [
        {
            "amount": {
                "currency": "$"
            },
            "category": {
                "coding": [
                    {
                        "code": "benefit"
                    }
                ]
            }
        }
    ]
}

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