Release
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5
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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 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>"
"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://terminology.hl7.org/CodeSystem/claim-type",
"code": "oral"
}
]
"identifier" : [{
"system" : "http://happyvalley.com/claim",
"value" : "12355"
}],
"status" : "active",
"type" : {
"coding" : [{
"system" : "http://terminology.hl7.org/CodeSystem/claim-type",
"code" : "oral"
}]
},
"use": "preauthorization",
"patient": {
"reference": "Patient/1"
"use" : "preauthorization",
"patient" : {
"reference" : "Patient/1"
},
"created": "2015-03-16",
"insurer": {
"reference": "Organization/2"
"created" : "2015-03-16",
"insurer" : {
"reference" : "Organization/2"
},
"provider": {
"reference": "Organization/1"
"provider" : {
"reference" : "Organization/1"
},
"priority": {
"coding": [
{
"code": "normal"
}
]
"priority" : {
"coding" : [{
"code" : "normal"
}]
},
"fundsReserve": {
"coding": [
{
"code": "provider"
}
]
"fundsReserve" : {
"coding" : [{
"code" : "provider"
}]
},
"payee": {
"type": {
"coding": [
{
"code": "provider"
}
]
"payee" : {
"type" : {
"coding" : [{
"code" : "provider"
}]
}
},
"careTeam": [
{
"sequence": 1,
"provider": {
"reference": "Practitioner/example"
}
"careTeam" : [{
"sequence" : 1,
"provider" : {
"reference" : "Practitioner/example"
}
],
"diagnosis": [
{
"sequence": 1,
"diagnosisCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/sid/icd-10",
"code": "K07.3"
}
]
}
}],
"diagnosis" : [{
"sequence" : 1,
"diagnosisCodeableConcept" : {
"coding" : [{
"system" : "http://hl7.org/fhir/sid/icd-10",
"code" : "K07.3"
}]
}
],
"insurance": [
{
"sequence": 1,
"focal": true,
"coverage": {
"reference": "Coverage/9876B1"
}
}],
"insurance" : [{
"sequence" : 1,
"focal" : true,
"coverage" : {
"reference" : "Coverage/9876B1"
}
],
"item": [
}],
"item" : [{
"sequence" : 1,
"careTeamSequence" : [1],
"diagnosisSequence" : [1],
"productOrService" : {
"coding" : [{
"system" : "http://example.org/fhir/oralservicecodes",
"code" : "ORTHPLAN"
}]
},
"servicedDate" : "2015-05-16",
"unitPrice" : {
"value" : 9000.00,
"currency" : "USD"
},
"net" : {
"value" : 9000.00,
"currency" : "USD"
},
"detail" : [{
"sequence" : 1,
"productOrService" : {
"coding" : [{
"system" : "http://example.org/fhir/oralservicecodes",
"code" : "ORTHOEXAM"
}]
},
"unitPrice" : {
"value" : 1000.00,
"currency" : "USD"
},
"net" : {
"value" : 1000.00,
"currency" : "USD"
}
},
{
"sequence": 1,
"careTeamSequence": [
1
],
"diagnosisSequence": [
1
],
"productOrService": {
"coding": [
{
"system": "http://example.org/fhir/oralservicecodes",
"code": "ORTHPLAN"
}
]
"sequence" : 2,
"productOrService" : {
"coding" : [{
"system" : "http://example.org/fhir/oralservicecodes",
"code" : "ORTHODIAG"
}]
},
"servicedDate": "2015-05-16",
"unitPrice": {
"value": 9000.00,
"currency": "USD"
"unitPrice" : {
"value" : 1500.00,
"currency" : "USD"
},
"net": {
"value": 9000.00,
"currency": "USD"
"net" : {
"value" : 1500.00,
"currency" : "USD"
}
},
{
"sequence" : 3,
"productOrService" : {
"coding" : [{
"system" : "http://example.org/fhir/oralservicecodes",
"code" : "ORTHOINITIAL"
}]
},
"detail": [
{
"sequence": 1,
"productOrService": {
"coding": [
{
"system": "http://example.org/fhir/oralservicecodes",
"code": "ORTHOEXAM"
}
]
},
"unitPrice": {
"value": 1000.00,
"currency": "USD"
},
"net": {
"value": 1000.00,
"currency": "USD"
}
},
{
"sequence": 2,
"productOrService": {
"coding": [
{
"system": "http://example.org/fhir/oralservicecodes",
"code": "ORTHODIAG"
}
]
},
"unitPrice": {
"value": 1500.00,
"currency": "USD"
},
"net": {
"value": 1500.00,
"currency": "USD"
}
},
{
"sequence": 3,
"productOrService": {
"coding": [
{
"system": "http://example.org/fhir/oralservicecodes",
"code": "ORTHOINITIAL"
}
]
},
"unitPrice": {
"value": 500.00,
"currency": "USD"
},
"net": {
"value": 500.00,
"currency": "USD"
}
},
{
"sequence": 4,
"productOrService": {
"coding": [
{
"system": "http://example.org/fhir/oralservicecodes",
"code": "ORTHOMONTHS"
}
]
},
"quantity": {
"value": 24
}
},
{
"sequence": 5,
"productOrService": {
"coding": [
{
"system": "http://example.org/fhir/oralservicecodes",
"code": "ORTHOPERIODIC"
}
]
},
"quantity": {
"value": 24
},
"unitPrice": {
"value": 250.00,
"currency": "USD"
},
"net": {
"value": 250.00,
"currency": "USD"
}
}
]
"unitPrice" : {
"value" : 500.00,
"currency" : "USD"
},
"net" : {
"value" : 500.00,
"currency" : "USD"
}
},
{
"sequence": 2,
"careTeamSequence": [
1
],
"productOrService": {
"coding": [
{
"system": "http://example.org/fhir/oralservicecodes",
"code": "21211"
}
]
"sequence" : 4,
"productOrService" : {
"coding" : [{
"system" : "http://example.org/fhir/oralservicecodes",
"code" : "ORTHOMONTHS"
}]
},
"servicedDate": "2014-08-16",
"unitPrice": {
"value": 105.00,
"currency": "USD"
"quantity" : {
"value" : 24
}
},
{
"sequence" : 5,
"productOrService" : {
"coding" : [{
"system" : "http://example.org/fhir/oralservicecodes",
"code" : "ORTHOPERIODIC"
}]
},
"net": {
"value": 105.00,
"currency": "USD"
"quantity" : {
"value" : 24
},
"bodySite": {
"coding": [
{
"system": "http://fdi.org/fhir/oraltoothcodes",
"code": "21"
}
]
"unitPrice" : {
"value" : 250.00,
"currency" : "USD"
},
"subSite": [
{
"coding": [
{
"system": "http://fdi.org/fhir/oralsurfacecodes",
"code": "L"
}
]
"net" : {
"value" : 250.00,
"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" : 750.00,
"currency" : "USD"
},
"net": {
"value": 1100.00,
"currency": "USD"
"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": 750.00,
"currency": "USD"
},
"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
4B
(v4.3.0)
hl7.fhir.r4b.core#4.3.0
R5
hl7.fhir.core#5.0.0
generated
on
Sat,
May
28,
2022
12:54+1000.
Sun,
Mar
26,
2023
15:24+1100.
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