{
  "resourceType" : "ClaimResponse",
  "identifier" : [" Identifier "], 
  "request" : " Reference(Claim) ",
  "ruleset" : " Coding ", 
  "originalRuleset" : " Coding ", 
  "created" : "<dateTime>", 
  "organization" : " Reference(Organization) ",
  "requestProvider" : " Reference(Practitioner) ",
  "requestOrganization" : " Reference(Organization) ", 
  "outcome" : "<code>", 
  "disposition" : "<string>", 
  "payeeType" : " Coding ", 
  "item" : [{ 
    "sequenceLinkId" : "<positiveInt>", 
    "noteNumber" : ["<positiveInt>"], 
    "adjudication" : [{ 
      "code" : " Coding ", 
      "amount" : " Quantity(Money) ", 
      "value" : "<decimal>"
    }],
    "detail" : [{ 
      "sequenceLinkId" : "<positiveInt>", 
      "adjudication" : [{ 
        "code" : " Coding ", 
        "amount" : " Quantity(Money) ", 
        "value" : "<decimal>"
      }],
      "subDetail" : [{ 
        "sequenceLinkId" : "<positiveInt>", 
        "adjudication" : [{ 
          "code" : " Coding ", 
          "amount" : " Quantity(Money) ",
          "value" : "<decimal>" 
        }]
      }]
    }]
  }],
  "addItem" : [{ 
    "sequenceLinkId" : ["<positiveInt>"],
    "service" : " Coding ", 
    "fee" : " Quantity(Money) ", 
    "noteNumberLinkId" : ["<positiveInt>"], 
    "adjudication" : [{ 
      "code" : " Coding ",
      "amount" : " Quantity(Money) ",
      "value" : "<decimal>" 
    }],
    "detail" : [{ 
      "service" : " Coding ", 
      "fee" : " Quantity(Money) ",
      "adjudication" : [{ 
        "code" : " Coding ", 
        "amount" : " Quantity(Money) ", 
        "value" : "<decimal>" 
      }]
    }]
  }],
  "error" : [{ 
    "sequenceLinkId" : "<positiveInt>", 
    "detailSequenceLinkId" : "<positiveInt>", 
    "subdetailSequenceLinkId" : "<positiveInt>", 
    "code" : " Coding "
  }],
  "totalCost" : " Quantity(Money) ", 
  "unallocDeductable" : " Quantity(Money) ", 
  "totalBenefit" : " Quantity(Money) ", 
  "paymentAdjustment" : " Quantity(Money) ", 
  "paymentAdjustmentReason" : " Coding ", 
  "paymentDate" : "<date>", 
  "paymentAmount" : " Quantity(Money) ", 
  "paymentRef" : " Identifier ", 
  "reserved" : " Coding ", 
  "form" : " Coding ", 
  "note" : [{ 
    "number" : "<positiveInt>", 
    "type" : " Coding ", 
    "text" : "<string>" 
  }],
  "coverage" : [{ 
    "sequence" : "<positiveInt>", 
    "focal" : "<boolean>", 
    "coverage" : " Reference(Coverage) ", 
    "businessArrangement" : "<string>", 
    "relationship" : " Coding ", 
    "preAuthRef" : ["<string>"], 
    "claimResponse" : " Reference(ClaimResponse) ", 
    "originalRuleset" : " Coding " 
  }]
}