Release 4B 5 Ballot

This page is part of the FHIR Specification (v4.3.0: R4B (v5.0.0-ballot: R5 Ballot - STU see ballot notes ). The current version which supercedes this version is 5.0.0 . For a full list of available versions, see the Directory of published versions . Page versions: R5 R4B R4 R3

Claim-example-oral-bridge.ttl

Example Claim/100156 (Turtle)

Financial Management Work Group Maturity Level : N/A Standards Status : Informative Compartments : Device , Encounter , Patient , Practitioner , RelatedPerson

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

PreAuthorization with Bridge and Crown 

@prefix fhir: <http://hl7.org/fhir/> .
@prefix owl: <http://www.w3.org/2002/07/owl#> .
@prefix rdfs: <http://www.w3.org/2000/01/rdf-schema#> .
@prefix xsd: <http://www.w3.org/2001/XMLSchema#> .

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

<http://hl7.org/fhir/Claim/100156> a fhir:Claim;

[a fhir:Claim;

  fhir:nodeRole fhir:treeRoot;
  fhir:Resource.id [ fhir:value "100156"];
  fhir:DomainResource.text [
     fhir:Narrative.status [ fhir:value "generated" ];
     fhir:Narrative.div "<div xmlns=\"http://www.w3.org/1999/xhtml\">A human-readable rendering of the Oral Health Claim</div>"
  ];
  fhir:DomainResource.contained [
     a fhir:Device;
     fhir:index 0;
     fhir:Resource.id [ fhir:value "device-bridge" ]
  ], [
     a fhir:ServiceRequest;
     fhir:index 1;
     fhir:Resource.id [ fhir:value "referral" ];
     fhir:ServiceRequest.status [ fhir:value "active" ];
     fhir:ServiceRequest.intent [ fhir:value "order" ];
     fhir:ServiceRequest.subject [
       fhir:link <http://hl7.org/fhir/Patient/1>;

       fhir:Reference.reference [ fhir:value "Patient/1" ]
     ]
  ];
  fhir:Claim.identifier [
     fhir:index 0;
     fhir:Identifier.system [ fhir:value "http://happyvalley.com/claim" ];
     fhir:Identifier.value [ fhir:value "123466" ]
  ];
  fhir:Claim.status [ fhir:value "active"];
  fhir:Claim.type [
     fhir:CodeableConcept.coding [
       fhir:index 0;
       fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/claim-type" ];
       fhir:Coding.code [ fhir:value "oral" ]
     ]
  ];
  fhir:Claim.use [ fhir:value "claim"];
  fhir:Claim.patient [
     fhir:link <http://hl7.org/fhir/Patient/1>;

     fhir:Reference.reference [ fhir:value "Patient/1" ]
  ];
  fhir:Claim.created [ fhir:value "2014-08-16"^^xsd:date];
  fhir:Claim.insurer [
     fhir:link <http://hl7.org/fhir/Organization/2>;

     fhir:Reference.reference [ fhir:value "Organization/2" ]
  ];
  fhir:Claim.provider [
     fhir:link <http://hl7.org/fhir/Organization/1>;

     fhir:Reference.reference [ fhir:value "Organization/1" ]
  ];
  fhir:Claim.priority [
     fhir:CodeableConcept.coding [
       fhir:index 0;
       fhir:Coding.code [ fhir:value "normal" ]
     ]
  ];
  fhir:Claim.related [
     fhir:index 0;
     fhir:Claim.related.claim [
       fhir:link <http://hl7.org/fhir/Claim/100151>;

       fhir:Reference.reference [ fhir:value "Claim/100151" ]
     ];
     fhir:Claim.related.relationship [
       fhir:CodeableConcept.coding [
         fhir:index 0;
         fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/ex-relatedclaimrelationship" ];
         fhir:Coding.code [ fhir:value "associated" ]
       ]
     ];
     fhir:Claim.related.reference [
       fhir:Identifier.value [ fhir:value "CASE156746B" ]
     ]
  ];
  fhir:Claim.payee [
     fhir:Claim.payee.type [
       fhir:CodeableConcept.coding [
         fhir:index 0;
         fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/payeetype" ];
         fhir:Coding.code [ fhir:value "other" ]
       ]
     ];
     fhir:Claim.payee.party [
       fhir:link <http://hl7.org/fhir/RelatedPerson/peter>;

       fhir:Reference.reference [ fhir:value "RelatedPerson/peter" ]
     ]
  ];
  fhir:Claim.referral [
     fhir:Reference.reference [ fhir:value "#referral" ]
  ];
  fhir:Claim.careTeam [
     fhir:index 0;
     fhir:Claim.careTeam.sequence [ fhir:value "1"^^xsd:positiveInteger ];
     fhir:Claim.careTeam.provider [
       fhir:link <http://hl7.org/fhir/Practitioner/example>;

       fhir:Reference.reference [ fhir:value "Practitioner/example" ]
     ]
  ];
  fhir:Claim.supportingInfo [
     fhir:index 0;
     fhir:Claim.supportingInfo.sequence [ fhir:value "1"^^xsd:positiveInteger ];
     fhir:Claim.supportingInfo.category [
       fhir:CodeableConcept.coding [
         fhir:index 0;
         fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/claiminformationcategory" ];
         fhir:Coding.code [ fhir:value "prosthesis" ]
       ]
     ];
     fhir:Claim.supportingInfo.code [
       fhir:CodeableConcept.coding [
         fhir:index 0;
         fhir:Coding.system [ fhir:value "http://hl7.org/fhir/ex-oralprostho" ];
         fhir:Coding.code [ fhir:value "2" ];
         fhir:Coding.display [ fhir:value "Maryland Bridge" ]
       ]
     ];
     fhir:Claim.supportingInfo.timingDate [ fhir:value "2001-04-07"^^xsd:date ]
  ];
  fhir:Claim.procedure [
     fhir:index 0;
     fhir:Claim.procedure.sequence [ fhir:value "1"^^xsd:positiveInteger ];
     fhir:Claim.procedure.date [ fhir:value "2014-07-04"^^xsd:date ];
     fhir:Claim.procedure.procedureCodeableConcept [
       fhir:CodeableConcept.text [ fhir:value "Resection of gum to increase exposed tooth." ]
     ]
  ];
  fhir:Claim.insurance [
     fhir:index 0;
     fhir:Claim.insurance.sequence [ fhir:value "1"^^xsd:positiveInteger ];
     fhir:Claim.insurance.focal [ fhir:value "true"^^xsd:boolean ];
     fhir:Claim.insurance.coverage [
       fhir:link <http://hl7.org/fhir/Coverage/9876B1>;

       fhir:Reference.reference [ fhir:value "Coverage/9876B1" ]
     ]
  ];
  fhir:Claim.item [
     fhir:index 0;
     fhir:Claim.item.sequence [ fhir:value "1"^^xsd:positiveInteger ];
     fhir:Claim.item.careTeamSequence [
       fhir:value "1"^^xsd:positiveInteger;
       fhir:index 0
     ];
     fhir:Claim.item.informationSequence [
       fhir:value "1"^^xsd:positiveInteger;
       fhir:index 0
     ];
     fhir:Claim.item.productOrService [
       fhir:CodeableConcept.coding [
         fhir:index 0;
         fhir:Coding.system [ fhir:value "http://example.org/fhir/oralservicecodes" ];
         fhir:Coding.code [ fhir:value "67221" ];
         fhir:Coding.display [ fhir:value "Maryland Bridge" ]
       ]
     ];
     fhir:Claim.item.servicedDate [ fhir:value "2014-08-16"^^xsd:date ];
     fhir:Claim.item.locationCodeableConcept [
       fhir:CodeableConcept.coding [
         fhir:index 0;
         fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/ex-serviceplace" ];
         fhir:Coding.code [ fhir:value "11" ]
       ]
     ];
     fhir:Claim.item.unitPrice [
       fhir:Money.value [ fhir:value "1400.00"^^xsd:decimal ];
       fhir:Money.currency [ fhir:value "USD" ]
     ];
     fhir:Claim.item.factor [ fhir:value "0.75"^^xsd:decimal ];
     fhir:Claim.item.net [
       fhir:Money.value [ fhir:value "1050.00"^^xsd:decimal ];
       fhir:Money.currency [ fhir:value "USD" ]
     ];
     fhir:Claim.item.udi [
       fhir:index 0;
       fhir:Reference.reference [ fhir:value "#device-bridge" ]
     ];
     fhir:Claim.item.bodySite [
       fhir:CodeableConcept.coding [

       fhir:index 0;
       fhir:Claim.item.bodySite.site [

         fhir:index 0;
         fhir:Coding.system [ fhir:value "http://fdi.org/fhir/oraltoothcodes" ];
         fhir:Coding.code [ fhir:value "01" ]

         fhir:CodeableReference.concept [
           fhir:CodeableConcept.coding [
             fhir:index 0;
             fhir:Coding.system [ fhir:value "http://fdi.org/fhir/oraltoothcodes" ];
             fhir:Coding.code [ fhir:value "01" ]
           ]
         ]

       ]
     ]
  ], [
     fhir:index 1;
     fhir:Claim.item.sequence [ fhir:value "2"^^xsd:positiveInteger ];
     fhir:Claim.item.careTeamSequence [
       fhir:value "1"^^xsd:positiveInteger;
       fhir:index 0
     ];
     fhir:Claim.item.productOrService [
       fhir:CodeableConcept.coding [
         fhir:index 0;
         fhir:Coding.system [ fhir:value "http://example.org/fhir/oralservicecodes" ];
         fhir:Coding.code [ fhir:value "21211" ]
       ]
     ];
     fhir:Claim.item.servicedDate [ fhir:value "2014-08-16"^^xsd:date ];
     fhir:Claim.item.locationCodeableConcept [
       fhir:CodeableConcept.coding [
         fhir:index 0;
         fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/ex-serviceplace" ];
         fhir:Coding.code [ fhir:value "11" ]
       ]
     ];
     fhir:Claim.item.unitPrice [
       fhir:Money.value [ fhir:value "105.00"^^xsd:decimal ];
       fhir:Money.currency [ fhir:value "USD" ]
     ];
     fhir:Claim.item.net [
       fhir:Money.value [ fhir:value "105.00"^^xsd:decimal ];
       fhir:Money.currency [ fhir:value "USD" ]
     ];
     fhir:Claim.item.bodySite [
       fhir:CodeableConcept.coding [
         fhir:index 0;
         fhir:Coding.system [ fhir:value "http://fdi.org/fhir/oraltoothcodes" ];
         fhir:Coding.code [ fhir:value "21" ]
       ]
     ];
     fhir:Claim.item.subSite [

       fhir:index 0;
       fhir:CodeableConcept.coding [

       fhir:Claim.item.bodySite.site [

         fhir:index 0;
         fhir:Coding.system [ fhir:value "http://fdi.org/fhir/oralsurfacecodes" ];
         fhir:Coding.code [ fhir:value "L" ]

         fhir:CodeableReference.concept [
           fhir:CodeableConcept.coding [
             fhir:index 0;
             fhir:Coding.system [ fhir:value "http://fdi.org/fhir/oraltoothcodes" ];
             fhir:Coding.code [ fhir:value "21" ]
           ]
         ]
       ];
       fhir:Claim.item.bodySite.subSite [
         fhir:index 0;
         fhir:CodeableConcept.coding [
           fhir:index 0;
           fhir:Coding.system [ fhir:value "http://fdi.org/fhir/oralsurfacecodes" ];
           fhir:Coding.code [ fhir:value "L" ]
         ]

       ]
     ]
  ], [
     fhir:index 2;
     fhir:Claim.item.sequence [ fhir:value "3"^^xsd:positiveInteger ];
     fhir:Claim.item.careTeamSequence [
       fhir:value "1"^^xsd:positiveInteger;
       fhir:index 0
     ];
     fhir:Claim.item.procedureSequence [
       fhir:value "1"^^xsd:positiveInteger;
       fhir:index 0
     ];
     fhir:Claim.item.productOrService [
       fhir:CodeableConcept.coding [
         fhir:index 0;
         fhir:Coding.system [ fhir:value "http://example.org/fhir/oralservicecodes" ];
         fhir:Coding.code [ fhir:value "27211" ]
       ]
     ];
     fhir:Claim.item.servicedDate [ fhir:value "2014-08-16"^^xsd:date ];
     fhir:Claim.item.locationCodeableConcept [
       fhir:CodeableConcept.coding [
         fhir:index 0;
         fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/ex-serviceplace" ];
         fhir:Coding.code [ fhir:value "11" ]
       ]
     ];
     fhir:Claim.item.unitPrice [
       fhir:Money.value [ fhir:value "1100.00"^^xsd:decimal ];
       fhir:Money.currency [ fhir:value "USD" ]
     ];
     fhir:Claim.item.net [
       fhir:Money.value [ fhir:value "1100.00"^^xsd:decimal ];
       fhir:Money.currency [ fhir:value "USD" ]
     ];
     fhir:Claim.item.bodySite [
       fhir:CodeableConcept.coding [

       fhir:index 0;
       fhir:Claim.item.bodySite.site [

         fhir:index 0;
         fhir:Coding.system [ fhir:value "http://fdi.org/fhir/oraltoothcodes" ];
         fhir:Coding.code [ fhir:value "24" ]

         fhir:CodeableReference.concept [
           fhir:CodeableConcept.coding [
             fhir:index 0;
             fhir:Coding.system [ fhir:value "http://fdi.org/fhir/oraltoothcodes" ];
             fhir:Coding.code [ fhir:value "24" ]
           ]
         ]

       ]
     ];
     fhir:Claim.item.detail [
       fhir:index 0;
       fhir:Claim.item.detail.sequence [ fhir:value "1"^^xsd:positiveInteger ];
       fhir:Claim.item.detail.productOrService [
         fhir:CodeableConcept.coding [
           fhir:index 0;
           fhir:Coding.system [ fhir:value "http://example.org/fhir/oralservicecodes" ];
           fhir:Coding.code [ fhir:value "27211" ]
         ]
       ];
       fhir:Claim.item.detail.unitPrice [
         fhir:Money.value [ fhir:value "1000.00"^^xsd:decimal ];
         fhir:Money.currency [ fhir:value "USD" ]
       ];
       fhir:Claim.item.detail.factor [ fhir:value "0.75"^^xsd:decimal ];
       fhir:Claim.item.detail.net [
         fhir:Money.value [ fhir:value "750.00"^^xsd:decimal ];
         fhir:Money.currency [ fhir:value "USD" ]
       ]
     ], [
       fhir:index 1;
       fhir:Claim.item.detail.sequence [ fhir:value "2"^^xsd:positiveInteger ];
       fhir:Claim.item.detail.productOrService [
         fhir:CodeableConcept.coding [
           fhir:index 0;
           fhir:Coding.system [ fhir:value "http://example.org/fhir/oralservicecodes" ];
           fhir:Coding.code [ fhir:value "lab" ]
         ]
       ];
       fhir:Claim.item.detail.unitPrice [
         fhir:Money.value [ fhir:value "350.00"^^xsd:decimal ];
         fhir:Money.currency [ fhir:value "USD" ]
       ];
       fhir:Claim.item.detail.net [
         fhir:Money.value [ fhir:value "350.00"^^xsd:decimal ];
         fhir:Money.currency [ fhir:value "USD" ]
       ]
     ]
  ];
  fhir:Claim.total [
     fhir:Money.value [ fhir:value "2255.00"^^xsd:decimal ];
     fhir:Money.currency [ fhir:value "USD" ]
  ] .

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

<http://hl7.org/fhir/Organization/2> a fhir:Organization .

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

<http://hl7.org/fhir/Claim/100151> a fhir:Claim .

<http://hl7.org/fhir/RelatedPerson/peter> a fhir:RelatedPerson .

<http://hl7.org/fhir/Practitioner/example> a fhir:Practitioner .

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

  ]] .


# - ontology header ------------------------------------------------------------

<http://hl7.org/fhir/Claim/100156.ttl> a owl:Ontology;
  owl:imports fhir:fhir.ttl;
  owl:versionIRI <http://build.fhir.org/Claim/100156.ttl> .

[a owl:Ontology;
  owl:imports fhir:fhir.ttl] .


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

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.