Release 5 FHIR CI-Build

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Example ClaimResponse/UR3503 (Turtle)

Maturity Level : N/A
Responsible Owner: Financial Management Work Group Standards Status : Informative Compartments : Group , Patient , Practitioner

Raw Turtle (+ also see Turtle/RDF Format Specification )

Unsolicited Pre-Authorization for social Dental Services 

@prefix fhir: <http://hl7.org/fhir/> .
@prefix owl: <http://www.w3.org/2002/07/owl#> .
@prefix rdf: <http://www.w3.org/1999/02/22-rdf-syntax-ns#> .

@prefix rdfs: <http://www.w3.org/2000/01/rdf-schema#> .
@prefix xsd: <http://www.w3.org/2001/XMLSchema#> .

# - resource -------------------------------------------------------------------

[a fhir:ClaimResponse ;

<http://hl7.org/fhir/ClaimResponse/UR3503> a fhir:ClaimResponse ;

  fhir:nodeRole fhir:treeRoot ;
  fhir:id [ fhir:v "UR3503"] ; # 
  fhir:text [
     fhir:status [ fhir:v "generated" ] ;
     fhir:div "<div xmlns=\"http://www.w3.org/1999/xhtml\">A sample unsolicited pre-authorization response which authorizes basic dental services to be performed for a patient.</div>"

     fhir:div [ fhir:v "<div xmlns=\"http://www.w3.org/1999/xhtml\">A sample unsolicited pre-authorization response which authorizes basic dental services to be performed for a patient.</div>"^^rdf:XMLLiteral ]

  ] ; # 
  fhir:identifier ( [
     fhir:system [ fhir:v "http://www.SocialBenefitsInc.com/fhir/ClaimResponse"^^xsd:anyURI ] ;

     fhir:system [
       fhir:v "http://www.SocialBenefitsInc.com/fhir/ClaimResponse"^^xsd:anyURI ;
       fhir:l <http://www.SocialBenefitsInc.com/fhir/ClaimResponse>
     ] ;

     fhir:value [ fhir:v "UR3503" ]
  ] ) ; # 
  fhir:status [ fhir:v "active"] ; # 
  fhir:type [
     fhir:coding ( [
       fhir:system [ fhir:v "http://terminology.hl7.org/CodeSystem/claim-type"^^xsd:anyURI ] ;

       fhir:system [
         fhir:v "http://terminology.hl7.org/CodeSystem/claim-type"^^xsd:anyURI ;
         fhir:l <http://terminology.hl7.org/CodeSystem/claim-type>
       ] ;

       fhir:code [ fhir:v "oral" ]
     ] )
  ] ; # 
  fhir:use [ fhir:v "preauthorization"] ; # 
  fhir:patient [

  fhir:subject [
     fhir:l <http://hl7.org/fhir/Patient/1> ;

     fhir:reference [ fhir:v "Patient/1" ]
  ] ; #   this is unsolicited therefore no reference to the preauthorization request exists  
  fhir:created [ fhir:v "2014-08-16"^^xsd:date] ; # 
  fhir:insurer [
     fhir:identifier [
       fhir:system [ fhir:v "http://www.jurisdiction.org/insurers"^^xsd:anyURI ] ;

       fhir:system [
         fhir:v "http://www.jurisdiction.org/insurers"^^xsd:anyURI ;
         fhir:l <http://www.jurisdiction.org/insurers>
       ] ;

       fhir:value [ fhir:v "444123" ]
     ] #   Social Benefits Inc.  
  ] ; # 
  fhir:requestor [
     fhir:l <http://hl7.org/fhir/Organization/1> ;

     fhir:reference [ fhir:v "Organization/1" ]
  ] ; # 
  fhir:outcome [ fhir:v "complete"] ; # 
  fhir:disposition [ fhir:v "The enclosed services are authorized for your provision within 30 days of this notice."] ; # 
  fhir:preAuthRef [ fhir:v "18SS12345"] ; # 
  fhir:payeeType [
     fhir:coding ( [
       fhir:system [ fhir:v "http://terminology.hl7.org/CodeSystem/payeetype"^^xsd:anyURI ] ;

       fhir:system [
         fhir:v "http://terminology.hl7.org/CodeSystem/payeetype"^^xsd:anyURI ;
         fhir:l <http://terminology.hl7.org/CodeSystem/payeetype>
       ] ;

       fhir:code [ fhir:v "provider" ]
     ] ) #   advise that assignment of benefit is allowed  
  ] ; # 
  fhir:addItem ( [
     fhir:itemSequence ( [ fhir:v "1"^^xsd:positiveInteger ] ) ; #   Exam  
     fhir:productOrService [
       fhir:coding ( [
         fhir:system [ fhir:v "http://example.org/fhir/oralservicecodes"^^xsd:anyURI ] ;

         fhir:system [
           fhir:v "http://example.org/fhir/oralservicecodes"^^xsd:anyURI ;
           fhir:l <http://example.org/fhir/oralservicecodes>
         ] ;

         fhir:code [ fhir:v "1101" ]
       ] )
     ] ;
     fhir:modifier ( [
       fhir:coding ( [
         fhir:system [ fhir:v "http://example.org/fhir/modifiers"^^xsd:anyURI ] ;

         fhir:system [
           fhir:v "http://example.org/fhir/modifiers"^^xsd:anyURI ;
           fhir:l <http://example.org/fhir/modifiers>
         ] ;

         fhir:code [ fhir:v "x" ] ;
         fhir:display [ fhir:v "None" ]
       ] )
     ] ) ;
     fhir:net [
       fhir:value [ fhir:v "250.00"^^xsd:decimal ] ;

       fhir:value [ fhir:v 250.00 ] ;

       fhir:currency [ fhir:v "USD" ] #   net set to same value as the eligible amount. Providers will only be reimbursed to the net\/eligible amount less the co-pay.  
     ] ;
     fhir:noteNumber ( [ fhir:v "101"^^xsd:positiveInteger ] ) ;
     fhir:adjudication ( [
       fhir:category [
         fhir:coding ( [
           fhir:code [ fhir:v "eligible" ]
         ] )
       ] ;
       fhir:amount [
         fhir:value [ fhir:v "250.00"^^xsd:decimal ] ;

         fhir:value [ fhir:v 250.00 ] ;

         fhir:currency [ fhir:v "USD" ]
       ]
     ] [
       fhir:category [
         fhir:coding ( [
           fhir:code [ fhir:v "copay" ]
         ] )
       ] ;
       fhir:amount [
         fhir:value [ fhir:v "10.00"^^xsd:decimal ] ;

         fhir:value [ fhir:v 10.00 ] ;

         fhir:currency [ fhir:v "USD" ]
       ]
     ] [
       fhir:category [
         fhir:coding ( [
           fhir:code [ fhir:v "eligpercent" ]
         ] )
       ] ;
       fhir:quantity [
         fhir:value [ fhir:v "100.00"^^xsd:decimal ]

         fhir:value [ fhir:v 100.00 ]

       ]
     ] [
       fhir:category [
         fhir:coding ( [
           fhir:code [ fhir:v "benefit" ]
         ] )
       ] ;
       fhir:amount [
         fhir:value [ fhir:v "240.00"^^xsd:decimal ] ;

         fhir:value [ fhir:v 240.00 ] ;

         fhir:currency [ fhir:v "USD" ] #   insurer will pay up to this amount.  
       ]
     ] )
  ] [
     fhir:itemSequence ( [ fhir:v "1"^^xsd:positiveInteger ] ) ; #   Xray Panel  
     fhir:productOrService [
       fhir:coding ( [
         fhir:system [ fhir:v "http://example.org/fhir/oralservicecodes"^^xsd:anyURI ] ;

         fhir:system [
           fhir:v "http://example.org/fhir/oralservicecodes"^^xsd:anyURI ;
           fhir:l <http://example.org/fhir/oralservicecodes>
         ] ;

         fhir:code [ fhir:v "2101" ] ;
         fhir:display [ fhir:v "Radiograph, series (12)" ]
       ] )
     ] ;
     fhir:net [
       fhir:value [ fhir:v "800.00"^^xsd:decimal ] ;

       fhir:value [ fhir:v 800.00 ] ;

       fhir:currency [ fhir:v "USD" ]
     ] ;
     fhir:adjudication ( [
       fhir:category [
         fhir:coding ( [
           fhir:code [ fhir:v "eligible" ]
         ] )
       ] ;
       fhir:amount [
         fhir:value [ fhir:v "800.00"^^xsd:decimal ] ;

         fhir:value [ fhir:v 800.00 ] ;

         fhir:currency [ fhir:v "USD" ]
       ]
     ] [
       fhir:category [
         fhir:coding ( [
           fhir:code [ fhir:v "eligpercent" ]
         ] )
       ] ;
       fhir:quantity [
         fhir:value [ fhir:v "100.00"^^xsd:decimal ]

         fhir:value [ fhir:v 100.00 ]

       ]
     ] [
       fhir:category [
         fhir:coding ( [
           fhir:code [ fhir:v "benefit" ]
         ] )
       ] ;
       fhir:amount [
         fhir:value [ fhir:v "800.00"^^xsd:decimal ] ;

         fhir:value [ fhir:v 800.00 ] ;

         fhir:currency [ fhir:v "USD" ]
       ]
     ] )
  ] ) ; #   Authorization details  ,   Authorization to receive an exam and an Xray panel  
  fhir:total ( [
     fhir:category [
       fhir:coding ( [
         fhir:code [ fhir:v "submitted" ]
       ] )
     ] ;
     fhir:amount [
       fhir:value [ fhir:v "1050.00"^^xsd:decimal ] ;

       fhir:value [ fhir:v 1050.00 ] ;

       fhir:currency [ fhir:v "USD" ]
     ]
  ] [
     fhir:category [
       fhir:coding ( [
         fhir:code [ fhir:v "benefit" ]
       ] )
     ] ;
     fhir:amount [
       fhir:value [ fhir:v "1040.00"^^xsd:decimal ] ;

       fhir:value [ fhir:v 1040.00 ] ;

       fhir:currency [ fhir:v "USD" ]
     ]
  ] ) ; # 
  fhir:processNote ( [
     fhir:number [ fhir:v "101"^^xsd:positiveInteger ] ;
     fhir:type [
       fhir:coding ( [
         fhir:system [ fhir:v "http://hl7.org/fhir/note-type"^^xsd:anyURI ] ;

         fhir:system [
           fhir:v "http://hl7.org/fhir/note-type"^^xsd:anyURI ;
           fhir:l <http://hl7.org/fhir/note-type>
         ] ;

         fhir:code [ fhir:v "print" ]
       ] )
     ] ;
     fhir:text [ fhir:v "Please submit a Pre-Authorization request if a more extensive examination or urgent services are required." ] ;
     fhir:language [
       fhir:coding ( [
         fhir:system [ fhir:v "urn:ietf:bcp:47"^^xsd:anyURI ] ;

         fhir:system [
           fhir:v "urn:ietf:bcp:47"^^xsd:anyURI ;
           fhir:l <urn:ietf:bcp:47>
         ] ;

         fhir:code [ fhir:v "en-CA" ]
       ] )
     ]
  ] ) ; # 
  fhir:insurance ( [
     fhir:sequence [ fhir:v "1"^^xsd:positiveInteger ] ;
     fhir:focal [ fhir:v "true"^^xsd:boolean ] ;

     fhir:focal [ fhir:v true ] ;

     fhir:coverage [
       fhir:l <http://hl7.org/fhir/Coverage/9876B1> ;

       fhir:reference [ fhir:v "Coverage/9876B1" ]
     ]
  ] )] . # 

  ] ) . # 

<http://hl7.org/fhir/Patient/1> a fhir:Patient .

<http://hl7.org/fhir/Organization/1> a fhir:Organization .

<http://hl7.org/fhir/Coverage/9876B1> a fhir:Coverage .


# -------------------------------------------------------------------------------------

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.