This
page
is
part
of
the
FHIR
Specification
(v3.0.2:
(v4.0.1:
R4
-
Mixed
Normative
and
STU
3).
)
in
it's
permanent
home
(it
will
always
be
available
at
this
URL).
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
R4
R3
R2
| Financial Management Work Group | Maturity Level : N/A |
|
Compartments : Device , Encounter , Patient , Practitioner , RelatedPerson |
Raw JSON ( canonical form + also see JSON Format Specification )
PreAuthorization with Orthodontic Treatment Plan
Financial
{
"resourceType": "Claim",
"id": "100153",
"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": "12355"
}
],
"status": "active",
"type": {
"coding": [
{
"system": "http://hl7.org/fhir/ex-claimtype",
"system": "http://terminology.hl7.org/CodeSystem/claim-type",
"code": "oral"
}
]
},
"use": "proposed",
"use": "preauthorization",
"patient": {
"reference": "Patient/1"
},
"created": "2015-03-16",
"insurer": {
"reference": "Organization/2"
},
"organization": {
"provider": {
"reference": "Organization/1"
},
"priority": {
"coding": [
{
"code": "normal"
}
]
},
"fundsReserve": {
"coding": [
{
"code": "provider"
}
]
},
"payee": {
"type": {
"coding": [
{
"code": "provider"
}
]
}
},
"careTeam": [
{
"sequence": 1,
"provider": {
"reference": "Practitioner/example"
}
}
],
"diagnosis": [
{
"sequence": 1,
"diagnosisCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/sid/icd-10",
"code": "123457"
}
]
}
}
],
"insurance": [
{
"sequence": 1,
"focal": true,
"coverage": {
"reference": "Coverage/9876B1"
}
}
],
"item": [
{
"sequence": 1,
"careTeamLinkId": [
"careTeamSequence": [
1
],
"diagnosisLinkId": [
"diagnosisSequence": [
1
],
"service": {
"productOrService": {
"coding": [
{
"system": "http://example.org/fhir/oralservicecodes",
"code": "ORTHPLAN"
}
]
},
"servicedDate": "2015-05-16",
"unitPrice": {
"value": 9000.00,
"system": "urn:iso:std:iso:4217",
"code": "USD"
"currency": "USD"
},
"net": {
"value": 9000.00,
"system": "urn:iso:std:iso:4217",
"code": "USD"
"currency": "USD"
},
"detail": [
{
"sequence": 1,
"service": {
"productOrService": {
"coding": [
{
"system": "http://example.org/fhir/oralservicecodes",
"code": "ORTHOEXAM"
}
]
},
"unitPrice": {
"value": 1000.00,
"system": "urn:iso:std:iso:4217",
"code": "USD"
"currency": "USD"
},
"net": {
"value": 1000.00,
"system": "urn:iso:std:iso:4217",
"code": "USD"
"currency": "USD"
}
},
{
"sequence": 2,
"service": {
"productOrService": {
"coding": [
{
"system": "http://example.org/fhir/oralservicecodes",
"code": "ORTHODIAG"
}
]
},
"unitPrice": {
"value": 1500.00,
"system": "urn:iso:std:iso:4217",
"code": "USD"
"currency": "USD"
},
"net": {
"value": 1500.00,
"system": "urn:iso:std:iso:4217",
"code": "USD"
"currency": "USD"
}
},
{
"sequence": 3,
"service": {
"productOrService": {
"coding": [
{
"system": "http://example.org/fhir/oralservicecodes",
"code": "ORTHOINITIAL"
}
]
},
"unitPrice": {
"value": 500.00,
"system": "urn:iso:std:iso:4217",
"code": "USD"
"currency": "USD"
},
"net": {
"value": 500.00,
"system": "urn:iso:std:iso:4217",
"code": "USD"
"currency": "USD"
}
},
{
"sequence": 4,
"service": {
"productOrService": {
"coding": [
{
"system": "http://example.org/fhir/oralservicecodes",
"code": "ORTHOMONTHS"
}
]
},
"quantity": {
"value": 24
}
},
{
"sequence": 5,
"service": {
"productOrService": {
"coding": [
{
"system": "http://example.org/fhir/oralservicecodes",
"code": "ORTHOPERIODIC"
}
]
},
"quantity": {
"value": 24
},
"unitPrice": {
"value": 250.00,
"system": "urn:iso:std:iso:4217",
"code": "USD"
"currency": "USD"
},
"net": {
"value": 250.00,
"system": "urn:iso:std:iso:4217",
"code": "USD"
"currency": "USD"
}
}
]
},
{
"sequence": 2,
"careTeamLinkId": [
"careTeamSequence": [
1
],
"service": {
"productOrService": {
"coding": [
{
"system": "http://example.org/fhir/oralservicecodes",
"code": "21211"
}
]
},
"servicedDate": "2014-08-16",
"unitPrice": {
"value": 105.00,
"system": "urn:iso:std:iso:4217",
"code": "USD"
"currency": "USD"
},
"net": {
"value": 105.00,
"system": "urn:iso:std:iso:4217",
"code": "USD"
"currency": "USD"
},
"bodySite": {
"coding": [
{
"system": "http://fdi.org/fhir/oraltoothcodes",
"code": "21"
}
]
},
"subSite": [
{
"coding": [
{
"system": "http://fdi.org/fhir/oralsurfacecodes",
"code": "L"
}
]
}
]
},
{
"sequence": 3,
"careTeamLinkId": [
"careTeamSequence": [
1
],
"service": {
"productOrService": {
"coding": [
{
"system": "http://example.org/fhir/oralservicecodes",
"code": "27211"
}
]
},
"servicedDate": "2014-08-16",
"unitPrice": {
"value": 1100.00,
"system": "urn:iso:std:iso:4217",
"code": "USD"
"currency": "USD"
},
"net": {
"value": 1100.00,
"system": "urn:iso:std:iso:4217",
"code": "USD"
"currency": "USD"
},
"bodySite": {
"coding": [
{
"system": "http://fdi.org/fhir/oraltoothcodes",
"code": "36"
}
]
},
"detail": [
{
"sequence": 1,
"service": {
"productOrService": {
"coding": [
{
"system": "http://example.org/fhir/oralservicecodes",
"code": "27211"
}
]
},
"unitPrice": {
"value": 750.00,
"system": "urn:iso:std:iso:4217",
"code": "USD"
"currency": "USD"
},
"net": {
"value": 750.00,
"system": "urn:iso:std:iso:4217",
"code": "USD"
"currency": "USD"
}
},
{
"sequence": 2,
"service": {
"productOrService": {
"coding": [
{
"system": "http://example.org/fhir/oralservicecodes",
"code": "lab"
}
]
},
"unitPrice": {
"value": 350.00,
"system": "urn:iso:std:iso:4217",
"code": "USD"
"currency": "USD"
},
"net": {
"value": 350.00,
"system": "urn:iso:std:iso:4217",
"code": "USD"
"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.
®©
HL7.org
2011+.
FHIR
Release
3
(STU;
v3.0.2-11200)
4
(Technical
Correction
#1)
(v4.0.1)
generated
on
Thurs,
Oct
24,
Fri,
Nov
1,
2019
11:53+1100.
09:34+1100.
QA
Page
Links:
Search
|
Version
History
|
Table
of
Contents
|
Credits
|
Compare
to
DSTU2
R3
|
|
Propose
a
change