{
  "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"
    }
  }
}