{

"resourceType": "ClaimResponse",
"id": "R3500",
"text": {
  "status": "generated",
  "div": "<div xmlns=\"http://www.w3.org/1999/xhtml\">A human-readable rendering of the ClaimResponse</div>"
},
"identifier": [
  {
    "system": "http://www.BenefitsInc.com/fhir/remittance",
    "value": "R3500"
  }
],
"status": "active",
"patient": {
  "reference": "Patient/1"
},
"created": "2014-08-16",
"insurer": {
  "identifier": {
    "system": "http://www.jurisdiction.org/insurers",
    "value": "555123"
  }
},
"requestProvider": {
  "reference": "Practitioner/1"
},
"requestOrganization": {
  "reference": "Organization/1"
},
"request": {
  "reference": "http://www.BenefitsInc.com/fhir/Claim/15476332402"
},
"outcome": {
  "coding": [
    {
      "system": "http://hl7.org/fhir/remittance-outcome",
      "code": "complete"
    }
  ]
},
"disposition": "Claim settled as per contract.",
"payeeType": {
  "coding": [
    {
      "system": "http://hl7.org/fhir/payeetype",
      "code": "provider"
    }
  ]
},
"item": [
  {
    "sequenceLinkId": 1,
    "adjudication": [
      {
        "category": {
          "coding": [
            {
              "code": "eligible"
            }
          ]
        },
        "amount": {
          "value": 135.57,
          "system": "urn:iso:std:iso:4217",
          "code": "USD"
        }
      },
      {
        "category": {
          "coding": [
            {
              "code": "copay"
            }
          ]
        },
        "amount": {
          "value": 10.00,
          "system": "urn:iso:std:iso:4217",
          "code": "USD"
        }
      },
      {
        "category": {
          "coding": [
            {
              "code": "eligpercent"
            }
          ]
        },
        "value": 80.00
      },
      {
        "category": {
          "coding": [
            {
              "code": "benefit"
            }
          ]
        },
        "amount": {
          "value": 100.47,
          "system": "urn:iso:std:iso:4217",
          "code": "USD"
        }
      }
    ]
  }
],
"totalCost": {
  "value": 135.57,
  "system": "urn:iso:std:iso:4217",
  "code": "USD"
},
"totalBenefit": {
  "value": 100.47,
  "system": "urn:iso:std:iso:4217",
  "code": "USD"
},
"payment": {
  "type": {
    "coding": [
      {
        "system": "http://hl7.org/fhir/ex-paymenttype",
        "code": "complete"
      }
    ]
  },
  "date": "2014-08-31",
  "amount": {
    "value": 100.47,
    "system": "urn:iso:std:iso:4217",
    "code": "USD"
  },
  "identifier": {
    "system": "http://www.BenefitsInc.com/fhir/paymentidentifier",
    "value": "201408-2-1569478"
  }
}

}