{
    "resourceType": "ClaimResponse",
    "id": "a3a42483-ee29-45a6-aa1a-4f6f1fb2cc10",
    "text": {
        "status": "generated",
        "div": "<div xmlns=\"http://www.w3.org/1999/xhtml\">A human-readable rendering of the ClaimResponse to Claim Oral Average with additional items</div>"
    },
    "identifier": [
        {
            "system": "http://cvs.com/claim",
            "value": "7612345"
        }
    ],
    "status": "active",
    "type": {
        "coding": [
            {
                "system": "http://terminology.hl7.org/CodeSystem/claim-type",
                "code": "pharmacy"
            }
        ]
    },
    "use": "claim",
    "patient": {
        "reference": "Patient/id2"
    },
    "created": "2019-9-13",
    "insurer": {
        "identifier": {
            "system": "http://www.jurisdiction.org/insurers",
            "value": "555123"
        }
    },
    "requestor": {
        "reference": "Organization/1456"
    },
    "request": {
        "identifier": {
            "system": "http://cvs.com/claim",
            "value": "7612345"
        }
    },
    "outcome": "complete",
    "disposition": "RTBI pre-determination.",
    "payeeType": {
        "coding": [
            {
                "system": "http://terminology.hl7.org/CodeSystem/payeetype",
                "code": "other"
            }
        ]
    },
    "item": [
        {
            "itemSequence": 1,
            "adjudication": [
                {
                    "category": {
                        "coding": [
                            {
                                "code": "benefit"
                            }
                        ]
                    },
                    "amount": {
                        "value": 0,
                        "currency": "USD"
                    }
                },
                {
                    "category": {
                        "coding": [
                            {
                                "code": "copay"
                            }
                        ]
                    },
                    "amount": {
                        "value": 25,
                        "currency": "USD"
                    }
                }
            ]
        }
    ],
    "addItem": [
        {
            "itemSequence": [
                1
            ],
            "productOrService": {
                "coding": [
                    {
                        "code": "51079-456-20",
                        "display": "Simvastatin"
                    }
                ]
            },
            "net": {
                "value": 0,
                "currency": "USD"
            },
            "noteNumber": [
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            ],
            "adjudication": [
                {
                    "category": {
                        "coding": [
                            {
                                "code": "benefit"
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                        ]
                    },
                    "amount": {
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                        "currency": "USD"
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                },
                {
                    "category": {
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                                "code": "copay"
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                        ]
                    },
                    "amount": {
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                        "currency": "USD"
                    }
                }
            ]
        }
    ],
    "payment": {
        "type": {
            "coding": [
                {
                    "system": "http://terminology.hl7.org/CodeSystem/ex-paymenttype",
                    "code": "complete"
                }
            ]
        },
        "date": "2019-9-13",
        "amount": {
            "value": 0,
            "currency": "USD"
        },
        "identifier": {
            "system": "http://www.Humana.com/fhir/paymentidentifier",
            "value": "201408-2-15507"
        }
    },
    "processNote": [
        {
            "number": 101,
            "type": "print",
            "text": "Connectathon 22.",
            "language": {
                "coding": [
                    {
                        "system": "urn:ietf:bcp:47",
                        "code": "en-CA"
                    }
                ]
            }
        }
    ]
}