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| Responsible Owner: Financial Management Work Group | Standards Status : Informative | Compartments : Device , Encounter , Group , Patient , Practitioner , RelatedPerson |
Raw JSON ( canonical form + also see JSON Format Specification )
Average dental Claim with Information (Missing Teeth and Student)
Financial
{
"resourceType": "Claim",
"id": "100151",
"text": {
"status": "generated",
"div": "<div xmlns=\"http://www.w3.org/1999/xhtml\">A human-readable rendering of the Oral Health Claim</div>"
"resourceType" : "Claim",
"id" : "100151",
"text" : {
"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\">A human-readable rendering of the Oral Health Claim</div>"
},
"identifier": [
{
"system": "http://happyvalley.com/claim",
"value": "12346"
}
],
"status": "active",
"type": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/claim-type",
"code": "oral"
}
]
"identifier" : [{
"system" : "http://happyvalley.com/claim",
"value" : "12346"
}],
"status" : "active",
"type" : {
"coding" : [{
"system" : "http://terminology.hl7.org/CodeSystem/claim-type",
"code" : "oral"
}]
},
"use": "claim",
"patient": {
"reference": "Patient/1"
"use" : "claim",
"subject" : {
"reference" : "Patient/1"
},
"created": "2014-08-16",
"insurer": {
"reference": "Organization/2"
"created" : "2014-08-16",
"insurer" : {
"reference" : "Organization/2"
},
"provider": {
"reference": "Organization/1"
"provider" : {
"reference" : "Organization/1"
},
"priority": {
"coding": [
{
"code": "normal"
}
]
"priority" : {
"coding" : [{
"code" : "normal"
}]
},
"payee": {
"type": {
"coding": [
{
"code": "provider"
}
]
"payee" : {
"type" : {
"coding" : [{
"code" : "provider"
}]
}
},
"careTeam": [
{
"sequence": 1,
"provider": {
"reference": "Practitioner/example"
}
"careTeam" : [{
"sequence" : 1,
"provider" : {
"reference" : "Practitioner/example"
}
],
"supportingInfo": [
{
"sequence": 1,
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/claiminformationcategory",
"code": "missingtooth"
}
]
},
"code": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/ex-tooth",
"code": "15"
}
]
},
"timingDate": "2012-04-07",
"reason": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/missingtoothreason",
"code": "e"
}
]
}
}],
"supportingInfo" : [{
"sequence" : 1,
"category" : {
"coding" : [{
"system" : "http://terminology.hl7.org/CodeSystem/claiminformationcategory",
"code" : "missingtooth"
}]
},
{
"sequence": 2,
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/claiminformationcategory",
"code": "exception"
}
]
},
"code": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/claim-exception",
"code": "student"
}
]
},
"valueString": "Happy Valley Community College"
"code" : {
"coding" : [{
"system" : "http://terminology.hl7.org/CodeSystem/ex-tooth",
"code" : "15"
}]
},
"timingDateTime" : "2012-04-07",
"reason" : {
"coding" : [{
"system" : "http://terminology.hl7.org/CodeSystem/missingtoothreason",
"code" : "e"
}]
}
],
"diagnosis": [
{
"sequence": 1,
"diagnosisCodeableConcept": {
"coding": [
{
"code": "123456"
}
]
}
},
{
"sequence" : 2,
"category" : {
"coding" : [{
"system" : "http://terminology.hl7.org/CodeSystem/claiminformationcategory",
"code" : "exception"
}]
},
"code" : {
"coding" : [{
"system" : "http://terminology.hl7.org/CodeSystem/claim-exception",
"code" : "student"
}]
},
"valueString" : "Happy Valley Community College"
}],
"diagnosis" : [{
"sequence" : 1,
"diagnosisCodeableConcept" : {
"coding" : [{
"code" : "123456"
}]
}
],
"insurance": [
{
"sequence": 1,
"focal": true,
"coverage": {
"reference": "Coverage/9876B1"
}
}],
"insurance" : [{
"sequence" : 1,
"focal" : true,
"coverage" : {
"reference" : "Coverage/9876B1"
}
],
"item": [
{
"sequence": 1,
"careTeamSequence": [
1
],
"productOrService": {
"coding": [
{
"system": "http://example.org/fhir/oralservicecodes",
"code": "1200"
}
]
},
"servicedDate": "2014-08-16",
"unitPrice": {
"value": 135.57,
"currency": "USD"
},
"net": {
"value": 135.57,
"currency": "USD"
}
}],
"item" : [{
"sequence" : 1,
"careTeamSequence" : [1],
"productOrService" : {
"coding" : [{
"system" : "http://example.org/fhir/oralservicecodes",
"code" : "1200"
}]
},
{
"sequence": 2,
"careTeamSequence": [
1
],
"productOrService": {
"coding": [
{
"system": "http://example.org/fhir/oralservicecodes",
"code": "21211"
}
]
},
"servicedDate": "2014-08-16",
"unitPrice": {
"value": 105.00,
"currency": "USD"
},
"net": {
"value": 105.00,
"currency": "USD"
},
"bodySite": {
"coding": [
{
"system": "http://fdi.org/fhir/oraltoothcodes",
"code": "21"
}
]
},
"subSite": [
{
"coding": [
{
"system": "http://fdi.org/fhir/oralsurfacecodes",
"code": "L"
}
]
"servicedDate" : "2014-08-16",
"unitPrice" : {
"value" : 135.57,
"currency" : "USD"
},
"net" : {
"value" : 135.57,
"currency" : "USD"
}
},
{
"sequence" : 2,
"careTeamSequence" : [1],
"productOrService" : {
"coding" : [{
"system" : "http://example.org/fhir/oralservicecodes",
"code" : "21211"
}]
},
"servicedDate" : "2014-08-16",
"unitPrice" : {
"value" : 105.00,
"currency" : "USD"
},
"net" : {
"value" : 105.00,
"currency" : "USD"
},
"bodySite" : [{
"site" : [{
"concept" : {
"coding" : [{
"system" : "http://fdi.org/fhir/oraltoothcodes",
"code" : "21"
}]
}
]
}],
"subSite" : [{
"coding" : [{
"system" : "http://fdi.org/fhir/oralsurfacecodes",
"code" : "L"
}]
}]
}]
},
{
"sequence" : 3,
"careTeamSequence" : [1],
"productOrService" : {
"coding" : [{
"system" : "http://example.org/fhir/oralservicecodes",
"code" : "27211"
}]
},
{
"sequence": 3,
"careTeamSequence": [
1
],
"productOrService": {
"coding": [
{
"system": "http://example.org/fhir/oralservicecodes",
"code": "27211"
}
]
"servicedDate" : "2014-08-16",
"unitPrice" : {
"value" : 1100.00,
"currency" : "USD"
},
"net" : {
"value" : 1100.00,
"currency" : "USD"
},
"bodySite" : [{
"site" : [{
"concept" : {
"coding" : [{
"system" : "http://fdi.org/fhir/oraltoothcodes",
"code" : "36"
}]
}
}]
}],
"detail" : [{
"sequence" : 1,
"productOrService" : {
"coding" : [{
"system" : "http://example.org/fhir/oralservicecodes",
"code" : "27211"
}]
},
"servicedDate": "2014-08-16",
"unitPrice": {
"value": 1100.00,
"currency": "USD"
"unitPrice" : {
"value" : 1000.00,
"currency" : "USD"
},
"net": {
"value": 1100.00,
"currency": "USD"
"factor" : 0.75,
"net" : {
"value" : 750.00,
"currency" : "USD"
}
},
{
"sequence" : 2,
"productOrService" : {
"coding" : [{
"system" : "http://example.org/fhir/oralservicecodes",
"code" : "lab"
}]
},
"bodySite": {
"coding": [
{
"system": "http://fdi.org/fhir/oraltoothcodes",
"code": "36"
}
]
"unitPrice" : {
"value" : 350.00,
"currency" : "USD"
},
"detail": [
{
"sequence": 1,
"productOrService": {
"coding": [
{
"system": "http://example.org/fhir/oralservicecodes",
"code": "27211"
}
]
},
"unitPrice": {
"value": 1000.00,
"currency": "USD"
},
"factor": 0.75,
"net": {
"value": 750.00,
"currency": "USD"
}
},
{
"sequence": 2,
"productOrService": {
"coding": [
{
"system": "http://example.org/fhir/oralservicecodes",
"code": "lab"
}
]
},
"unitPrice": {
"value": 350.00,
"currency": "USD"
},
"net": {
"value": 350.00,
"currency": "USD"
}
}
]
}
]
"net" : {
"value" : 350.00,
"currency" : "USD"
}
}]
}]
}
Usage note: every effort has been made to ensure that the examples are correct and useful, but they are not a normative part of the specification.
FHIR
®©
HL7.org
2011+.
FHIR
Release
4
(Technical
Correction
#1)
(v4.0.1)
R6
hl7.fhir.core#6.0.0-ballot3
generated
on
Fri,
Nov
1,
2019
09:34+1100.
QA
Page
7,
2025
08:55+0000.
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