{
  "resourceType": "ClaimResponse",
  "id": "R3501",
  "identifier": [
    {
      "system": "http://www.BenefitsInc.com/fhir/remittance",
      "value": "R3501"
    }
  ],
  "status": "active",
  "type": {
    "coding": [
      {
        "system": "http://terminology.hl7.org/CodeSystem/claim-type",
        "code": "oral"
      }
    ]
  },
  "use": "claim",
  "patient": {
    "reference": "Patient/1"
  },
  "created": "2014-08-16",
  "insurer": {
    "identifier": {
      "system": "http://www.jurisdiction.org/insurers",
      "value": "555123"
    }
  },
  "requestor": {
    "reference": "Practitioner/1"
  },
  "request": {
    "reference": "Claim/100156"
  },
  "outcome": "error",
  "disposition": "Claim could not be processed",
  "formCode": {
    "coding": [
      {
        "system": "http://terminology.hl7.org/CodeSystem/forms-codes",
        "code": "2"
      }
    ]
  },
  "processNote": [
    {
      "number": 1,
      "type": "display",
      "text": "Invalid claim",
      "language": {
        "coding": [
          {
            "system": "urn:ietf:bcp:47",
            "code": "en-CA"
          }
        ]
      }
    }
  ],
  "communicationRequest": [
    {
      "reference": "CommunicationRequest/fm-solicit"
    }
  ],
  "error": [
    {
      "itemSequence": 3,
      "detailSequence": 2,
      "code": {
        "coding": [
          {
            "system": "http://terminology.hl7.org/CodeSystem/adjudication-error",
            "code": "a002"
          }
        ]
      }
    }
  ],
  "meta": {
    "tag": [
      {
        "system": "http://terminology.hl7.org/CodeSystem/v3-ActReason",
        "code": "HTEST",
        "display": "test health data"
      }
    ]
  }
}