Release
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5
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R4
(v5.0.0:
R5
-
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Normative
and
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| Financial Management Work Group | Maturity Level : N/A | Standards Status : Informative | Compartments : Device , Encounter , Patient , Practitioner , RelatedPerson |
Raw JSON ( canonical form + also see JSON Format Specification )
PreAuthorization with Bridge and Crown
Financial
{
"resourceType": "Claim",
"id": "100156",
"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" : "100156",
"text" : {
"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\">A human-readable rendering of the Oral Health Claim</div>"
},
"contained": [
{
"resourceType": "Device",
"id": "device-bridge"
},
{
"resourceType": "ServiceRequest",
"id": "referral",
"status": "active",
"intent": "order",
"subject": {
"reference": "Patient/1"
}
}
],
"identifier": [
{
"system": "http://happyvalley.com/claim",
"value": "123466"
"contained" : [{
"resourceType" : "Device",
"id" : "device-bridge"
},
{
"resourceType" : "ServiceRequest",
"id" : "referral",
"status" : "active",
"intent" : "order",
"subject" : {
"reference" : "Patient/1"
}
],
"status": "active",
"type": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/claim-type",
"code": "oral"
}
]
}],
"identifier" : [{
"system" : "http://happyvalley.com/claim",
"value" : "123466"
}],
"status" : "active",
"type" : {
"coding" : [{
"system" : "http://terminology.hl7.org/CodeSystem/claim-type",
"code" : "oral"
}]
},
"use": "claim",
"patient": {
"reference": "Patient/1"
"use" : "claim",
"patient" : {
"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"
}]
},
"related": [
{
"claim": {
"reference": "Claim/100151"
},
"relationship": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/ex-relatedclaimrelationship",
"code": "associated"
}
]
},
"reference": {
"value": "CASE156746B"
}
"related" : [{
"claim" : {
"reference" : "Claim/100151"
},
"relationship" : {
"coding" : [{
"system" : "http://terminology.hl7.org/CodeSystem/ex-relatedclaimrelationship",
"code" : "associated"
}]
},
"reference" : {
"value" : "CASE156746B"
}
],
"payee": {
"type": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/payeetype",
"code": "other"
}
]
}],
"payee" : {
"type" : {
"coding" : [{
"system" : "http://terminology.hl7.org/CodeSystem/payeetype",
"code" : "other"
}]
},
"party": {
"reference": "RelatedPerson/peter"
"party" : {
"reference" : "RelatedPerson/peter"
}
},
"referral": {
"reference": "#referral"
"referral" : {
"reference" : "#referral"
},
"careTeam": [
{
"sequence": 1,
"provider": {
"reference": "Practitioner/example"
}
}
],
"supportingInfo": [
{
"sequence": 1,
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/claiminformationcategory",
"code": "prosthesis"
}
]
},
"code": {
"coding": [
{
"system": "http://hl7.org/fhir/ex-oralprostho",
"code": "2",
"display": "Maryland Bridge"
}
]
},
"timingDate": "2001-04-07"
"careTeam" : [{
"sequence" : 1,
"provider" : {
"reference" : "Practitioner/example"
}
],
"procedure": [
{
"sequence": 1,
"date": "2014-07-04",
"procedureCodeableConcept": {
"text": "Resection of gum to increase exposed tooth."
}
}],
"supportingInfo" : [{
"sequence" : 1,
"category" : {
"coding" : [{
"system" : "http://terminology.hl7.org/CodeSystem/claiminformationcategory",
"code" : "prosthesis"
}]
},
"code" : {
"coding" : [{
"system" : "http://hl7.org/fhir/ex-oralprostho",
"code" : "2",
"display" : "Maryland Bridge"
}]
},
"timingDate" : "2001-04-07"
}],
"procedure" : [{
"sequence" : 1,
"date" : "2014-07-04",
"procedureCodeableConcept" : {
"text" : "Resection of gum to increase exposed tooth."
}
],
"insurance": [
{
"sequence": 1,
"focal": true,
"coverage": {
"reference": "Coverage/9876B1"
}
}],
"insurance" : [{
"sequence" : 1,
"focal" : true,
"coverage" : {
"reference" : "Coverage/9876B1"
}
],
"item": [
{
"sequence": 1,
"careTeamSequence": [
1
],
"informationSequence": [
1
],
"productOrService": {
"coding": [
{
"system": "http://example.org/fhir/oralservicecodes",
"code": "67221",
"display": "Maryland Bridge"
}
]
},
"servicedDate": "2014-08-16",
"locationCodeableConcept": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace",
"code": "11"
}
]
},
"unitPrice": {
"value": 1400.00,
"currency": "USD"
},
"factor": 0.75,
"net": {
"value": 1050.00,
"currency": "USD"
},
"udi": [
{
"reference": "#device-bridge"
}],
"item" : [{
"sequence" : 1,
"careTeamSequence" : [1],
"informationSequence" : [1],
"productOrService" : {
"coding" : [{
"system" : "http://example.org/fhir/oralservicecodes",
"code" : "67221",
"display" : "Maryland Bridge"
}]
},
"servicedDate" : "2014-08-16",
"locationCodeableConcept" : {
"coding" : [{
"system" : "http://terminology.hl7.org/CodeSystem/ex-serviceplace",
"code" : "11"
}]
},
"unitPrice" : {
"value" : 1400.00,
"currency" : "USD"
},
"factor" : 0.75,
"net" : {
"value" : 1050.00,
"currency" : "USD"
},
"udi" : [{
"reference" : "#device-bridge"
}],
"bodySite" : [{
"site" : [{
"concept" : {
"coding" : [{
"system" : "http://fdi.org/fhir/oraltoothcodes",
"code" : "01"
}]
}
],
"bodySite": {
"coding": [
{
"system": "http://fdi.org/fhir/oraltoothcodes",
"code": "01"
}
]
}
}]
}]
},
{
"sequence" : 2,
"careTeamSequence" : [1],
"productOrService" : {
"coding" : [{
"system" : "http://example.org/fhir/oralservicecodes",
"code" : "21211"
}]
},
{
"sequence": 2,
"careTeamSequence": [
1
],
"productOrService": {
"coding": [
{
"system": "http://example.org/fhir/oralservicecodes",
"code": "21211"
}
]
},
"servicedDate": "2014-08-16",
"locationCodeableConcept": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace",
"code": "11"
}
]
},
"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",
"locationCodeableConcept" : {
"coding" : [{
"system" : "http://terminology.hl7.org/CodeSystem/ex-serviceplace",
"code" : "11"
}]
},
"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],
"procedureSequence" : [1],
"productOrService" : {
"coding" : [{
"system" : "http://example.org/fhir/oralservicecodes",
"code" : "27211"
}]
},
{
"sequence": 3,
"careTeamSequence": [
1
],
"procedureSequence": [
1
],
"productOrService": {
"coding": [
{
"system": "http://example.org/fhir/oralservicecodes",
"code": "27211"
}
]
},
"servicedDate": "2014-08-16",
"locationCodeableConcept": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace",
"code": "11"
}
]
"servicedDate" : "2014-08-16",
"locationCodeableConcept" : {
"coding" : [{
"system" : "http://terminology.hl7.org/CodeSystem/ex-serviceplace",
"code" : "11"
}]
},
"unitPrice" : {
"value" : 1100.00,
"currency" : "USD"
},
"net" : {
"value" : 1100.00,
"currency" : "USD"
},
"bodySite" : [{
"site" : [{
"concept" : {
"coding" : [{
"system" : "http://fdi.org/fhir/oraltoothcodes",
"code" : "24"
}]
}
}]
}],
"detail" : [{
"sequence" : 1,
"productOrService" : {
"coding" : [{
"system" : "http://example.org/fhir/oralservicecodes",
"code" : "27211"
}]
},
"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": "24"
}
]
"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"
}
}
]
}
],
"total": {
"value": 2255.00,
"currency": "USD"
"net" : {
"value" : 350.00,
"currency" : "USD"
}
}]
}],
"total" : {
"value" : 2255.00,
"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)
R5
hl7.fhir.core#5.0.0
generated
on
Fri,
Nov
1,
2019
09:34+1100.
QA
Page
Sun,
Mar
26,
2023
15:24+1100.
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