Release
4B
5
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R4B
(v5.0.0:
R5
-
STU
).
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R3
| 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 )
Glasses Claim, 3 Tier, Secondary Coverage
Financial
{
"resourceType": "Claim",
"id": "660152",
"text": {
"status": "generated",
"div": "<div xmlns=\"http://www.w3.org/1999/xhtml\">A human-readable rendering of the Vision Claim for Glasses</div>"
"resourceType" : "Claim",
"id" : "660152",
"text" : {
"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\">A human-readable rendering of the Vision Claim for Glasses</div>"
},
"contained": [
{
"resourceType": "Device",
"id": "device-frame"
},
{
"resourceType": "Device",
"id": "device-lens"
}
],
"identifier": [
{
"system": "http://happysight.com/claim",
"value": "6612347"
}
],
"status": "active",
"type": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/claim-type",
"code": "vision"
}
]
"contained" : [{
"resourceType" : "Device",
"id" : "device-frame"
},
"use": "claim",
"patient": {
"reference": "Patient/1"
{
"resourceType" : "Device",
"id" : "device-lens"
}],
"identifier" : [{
"system" : "http://happysight.com/claim",
"value" : "6612347"
}],
"status" : "active",
"type" : {
"coding" : [{
"system" : "http://terminology.hl7.org/CodeSystem/claim-type",
"code" : "vision"
}]
},
"created": "2014-08-16",
"insurer": {
"reference": "Organization/2"
"use" : "claim",
"patient" : {
"reference" : "Patient/1"
},
"provider": {
"reference": "Organization/1"
"created" : "2014-08-16",
"insurer" : {
"reference" : "Organization/2"
},
"priority": {
"coding": [
{
"code": "normal"
}
]
"provider" : {
"reference" : "Organization/1"
},
"prescription": {
"reference": "http://www.optdocs.com/prescription/12345"
"priority" : {
"coding" : [{
"code" : "normal"
}]
},
"payee": {
"type": {
"coding": [
{
"code": "provider"
}
]
"prescription" : {
"reference" : "http://www.optdocs.com/prescription/12345"
},
"payee" : {
"type" : {
"coding" : [{
"code" : "provider"
}]
}
},
"careTeam": [
{
"sequence": 1,
"provider": {
"reference": "Practitioner/example"
}
"careTeam" : [{
"sequence" : 1,
"provider" : {
"reference" : "Practitioner/example"
}
],
"diagnosis": [
{
"sequence": 1,
"diagnosisCodeableConcept": {
"coding": [
{
"code": "654321"
}
]
}
}],
"diagnosis" : [{
"sequence" : 1,
"diagnosisCodeableConcept" : {
"coding" : [{
"code" : "654321"
}]
}
],
"insurance": [
{
"sequence": 1,
"focal": false,
"coverage": {
"reference": "Coverage/9876B1"
}],
"insurance" : [{
"sequence" : 1,
"focal" : false,
"coverage" : {
"reference" : "Coverage/9876B1"
},
"preAuthRef" : ["PR7652387237"],
"claimResponse" : {
"reference" : "ClaimResponse/R3500"
}
},
{
"sequence" : 2,
"focal" : true,
"coverage" : {
"reference" : "Coverage/9876B1"
},
"preAuthRef" : ["AB543GTD7567"]
}],
"item" : [{
"sequence" : 1,
"careTeamSequence" : [1],
"revenue" : {
"coding" : [{
"system" : "http://terminology.hl7.org/CodeSystem/ex-revenue-center",
"code" : "0010",
"display" : "Vision Clinic"
}]
},
"category" : {
"coding" : [{
"system" : "http://example.org/fhir/CodeSystem/benefit-subcategory",
"code" : "F6",
"display" : "Vision Coverage"
}]
},
"productOrService" : {
"coding" : [{
"system" : "http://example.org/fhir/CodeSystem/ex-visionservice",
"code" : "glasses"
}]
},
"modifier" : [{
"coding" : [{
"system" : "http://terminology.hl7.org/CodeSystem/modifiers",
"code" : "rooh"
}]
}],
"programCode" : [{
"coding" : [{
"system" : "http://terminology.hl7.org/CodeSystem/ex-programcode",
"code" : "none"
}]
}],
"servicedDate" : "2014-08-16",
"unitPrice" : {
"value" : 235.40,
"currency" : "USD"
},
"net" : {
"value" : 235.40,
"currency" : "USD"
},
"detail" : [{
"sequence" : 1,
"revenue" : {
"coding" : [{
"system" : "http://terminology.hl7.org/CodeSystem/ex-revenue-center",
"code" : "0010",
"display" : "Vision Clinic"
}]
},
"preAuthRef": [
"PR7652387237"
],
"claimResponse": {
"reference": "ClaimResponse/R3500"
}
"category" : {
"coding" : [{
"system" : "http://example.org/fhir/CodeSystem/benefit-subcategory",
"code" : "F6",
"display" : "Vision Coverage"
}]
},
"productOrService" : {
"coding" : [{
"system" : "http://example.org/fhir/CodeSystem/ex-visionservice",
"code" : "frame"
}]
},
"modifier" : [{
"coding" : [{
"system" : "http://terminology.hl7.org/CodeSystem/modifiers",
"code" : "rooh"
}]
}],
"unitPrice" : {
"value" : 100.00,
"currency" : "USD"
},
"factor" : 1.1,
"net" : {
"value" : 110.00,
"currency" : "USD"
},
"udi" : [{
"reference" : "#device-frame"
}]
},
{
"sequence": 2,
"focal": true,
"coverage": {
"reference": "Coverage/9876B1"
"sequence" : 2,
"revenue" : {
"coding" : [{
"system" : "http://terminology.hl7.org/CodeSystem/ex-revenue-center",
"code" : "0010",
"display" : "Vision Clinic"
}]
},
"preAuthRef": [
"AB543GTD7567"
]
}
],
"item": [
{
"sequence": 1,
"careTeamSequence": [
1
],
"revenue": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/ex-revenue-center",
"code": "0010",
"display": "Vision Clinic"
}
]
"category" : {
"coding" : [{
"system" : "http://example.org/fhir/CodeSystem/benefit-subcategory",
"code" : "F6",
"display" : "Vision Coverage"
}]
},
"category": {
"coding": [
{
"system": "http://example.org/fhir/CodeSystem/benefit-subcategory",
"code": "F6",
"display": "Vision Coverage"
}
]
"productOrService" : {
"coding" : [{
"system" : "http://example.org/fhir/CodeSystem/ex-visionservice",
"code" : "lens"
}]
},
"productOrService": {
"coding": [
{
"system": "http://example.org/fhir/CodeSystem/ex-visionservice",
"code": "glasses"
}
]
"programCode" : [{
"coding" : [{
"system" : "http://terminology.hl7.org/CodeSystem/ex-programcode",
"code" : "none"
}]
}],
"quantity" : {
"value" : 2
},
"modifier": [
{
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/modifiers",
"code": "rooh"
}
]
}
],
"programCode": [
{
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/ex-programcode",
"code": "none"
}
]
}
],
"servicedDate": "2014-08-16",
"unitPrice": {
"value": 235.40,
"currency": "USD"
"unitPrice" : {
"value" : 55.00,
"currency" : "USD"
},
"net": {
"value": 235.40,
"currency": "USD"
"net" : {
"value" : 110.00,
"currency" : "USD"
},
"detail": [
{
"sequence": 1,
"revenue": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/ex-revenue-center",
"code": "0010",
"display": "Vision Clinic"
}
]
},
"category": {
"coding": [
{
"system": "http://example.org/fhir/CodeSystem/benefit-subcategory",
"code": "F6",
"display": "Vision Coverage"
}
]
},
"productOrService": {
"coding": [
{
"system": "http://example.org/fhir/CodeSystem/ex-visionservice",
"code": "frame"
}
]
},
"modifier": [
{
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/modifiers",
"code": "rooh"
}
]
}
],
"unitPrice": {
"value": 100.00,
"currency": "USD"
},
"factor": 1.1,
"net": {
"value": 110.00,
"currency": "USD"
},
"udi": [
{
"reference": "#device-frame"
}
]
"subDetail" : [{
"sequence" : 1,
"revenue" : {
"coding" : [{
"system" : "http://terminology.hl7.org/CodeSystem/ex-revenue-center",
"code" : "0010",
"display" : "Vision Clinic"
}]
},
{
"sequence": 2,
"revenue": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/ex-revenue-center",
"code": "0010",
"display": "Vision Clinic"
}
]
},
"category": {
"coding": [
{
"system": "http://example.org/fhir/CodeSystem/benefit-subcategory",
"code": "F6",
"display": "Vision Coverage"
}
]
},
"productOrService": {
"coding": [
{
"system": "http://example.org/fhir/CodeSystem/ex-visionservice",
"code": "lens"
}
]
},
"programCode": [
{
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/ex-programcode",
"code": "none"
}
]
}
],
"quantity": {
"value": 2
},
"unitPrice": {
"value": 55.00,
"currency": "USD"
},
"net": {
"value": 110.00,
"currency": "USD"
},
"subDetail": [
{
"sequence": 1,
"revenue": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/ex-revenue-center",
"code": "0010",
"display": "Vision Clinic"
}
]
},
"category": {
"coding": [
{
"system": "http://example.org/fhir/CodeSystem/benefit-subcategory",
"code": "F6",
"display": "Vision Coverage"
}
]
},
"productOrService": {
"coding": [
{
"system": "http://example.org/fhir/CodeSystem/ex-visionservice",
"code": "lens"
}
]
},
"modifier": [
{
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/modifiers",
"code": "rooh"
}
]
}
],
"programCode": [
{
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/ex-programcode",
"code": "none"
}
]
}
],
"quantity": {
"value": 2
},
"unitPrice": {
"value": 30.00,
"currency": "USD"
},
"factor": 1.1,
"net": {
"value": 66.00,
"currency": "USD"
},
"udi": [
{
"reference": "#device-lens"
}
]
},
{
"sequence": 2,
"revenue": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/ex-revenue-center",
"code": "0010",
"display": "Vision Clinic"
}
]
},
"category": {
"coding": [
{
"system": "http://example.org/fhir/CodeSystem/benefit-subcategory",
"code": "F6",
"display": "Vision Coverage"
}
]
},
"productOrService": {
"coding": [
{
"system": "http://example.org/fhir/CodeSystem/ex-visionservice",
"code": "hardening"
}
]
},
"modifier": [
{
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/modifiers",
"code": "rooh"
}
]
}
],
"quantity": {
"value": 2
},
"unitPrice": {
"value": 15.00,
"currency": "USD"
},
"factor": 1.1,
"net": {
"value": 33.00,
"currency": "USD"
}
},
{
"sequence": 3,
"revenue": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/ex-revenue-center",
"code": "0010",
"display": "Vision Clinic"
}
]
},
"category": {
"coding": [
{
"system": "http://example.org/fhir/CodeSystem/benefit-subcategory",
"code": "F6",
"display": "Vision Coverage"
}
]
},
"productOrService": {
"coding": [
{
"system": "http://example.org/fhir/CodeSystem/ex-visionservice",
"code": "UV coating"
}
]
},
"modifier": [
{
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/modifiers",
"code": "rooh"
}
]
}
],
"quantity": {
"value": 2
},
"unitPrice": {
"value": 5.00,
"currency": "USD"
},
"factor": 1.1,
"net": {
"value": 11.00,
"currency": "USD"
}
}
]
"category" : {
"coding" : [{
"system" : "http://example.org/fhir/CodeSystem/benefit-subcategory",
"code" : "F6",
"display" : "Vision Coverage"
}]
},
{
"sequence": 3,
"revenue": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/ex-revenue-center",
"code": "0010",
"display": "Vision Clinic"
}
]
},
"category": {
"coding": [
{
"system": "http://example.org/fhir/CodeSystem/benefit-subcategory",
"code": "F6",
"display": "Vision Coverage"
}
]
},
"productOrService": {
"coding": [
{
"system": "http://example.org/fhir/CodeSystem/ex-visionservice",
"code": "fst"
}
]
},
"unitPrice": {
"value": 220.00,
"currency": "USD"
},
"factor": 0.07,
"net": {
"value": 15.40,
"currency": "USD"
}
"productOrService" : {
"coding" : [{
"system" : "http://example.org/fhir/CodeSystem/ex-visionservice",
"code" : "lens"
}]
},
"modifier" : [{
"coding" : [{
"system" : "http://terminology.hl7.org/CodeSystem/modifiers",
"code" : "rooh"
}]
}],
"programCode" : [{
"coding" : [{
"system" : "http://terminology.hl7.org/CodeSystem/ex-programcode",
"code" : "none"
}]
}],
"quantity" : {
"value" : 2
},
"unitPrice" : {
"value" : 30.00,
"currency" : "USD"
},
"factor" : 1.1,
"net" : {
"value" : 66.00,
"currency" : "USD"
},
"udi" : [{
"reference" : "#device-lens"
}]
},
{
"sequence" : 2,
"revenue" : {
"coding" : [{
"system" : "http://terminology.hl7.org/CodeSystem/ex-revenue-center",
"code" : "0010",
"display" : "Vision Clinic"
}]
},
"category" : {
"coding" : [{
"system" : "http://example.org/fhir/CodeSystem/benefit-subcategory",
"code" : "F6",
"display" : "Vision Coverage"
}]
},
"productOrService" : {
"coding" : [{
"system" : "http://example.org/fhir/CodeSystem/ex-visionservice",
"code" : "hardening"
}]
},
"modifier" : [{
"coding" : [{
"system" : "http://terminology.hl7.org/CodeSystem/modifiers",
"code" : "rooh"
}]
}],
"quantity" : {
"value" : 2
},
"unitPrice" : {
"value" : 15.00,
"currency" : "USD"
},
"factor" : 1.1,
"net" : {
"value" : 33.00,
"currency" : "USD"
}
]
}
]
},
{
"sequence" : 3,
"revenue" : {
"coding" : [{
"system" : "http://terminology.hl7.org/CodeSystem/ex-revenue-center",
"code" : "0010",
"display" : "Vision Clinic"
}]
},
"category" : {
"coding" : [{
"system" : "http://example.org/fhir/CodeSystem/benefit-subcategory",
"code" : "F6",
"display" : "Vision Coverage"
}]
},
"productOrService" : {
"coding" : [{
"system" : "http://example.org/fhir/CodeSystem/ex-visionservice",
"code" : "UV coating"
}]
},
"modifier" : [{
"coding" : [{
"system" : "http://terminology.hl7.org/CodeSystem/modifiers",
"code" : "rooh"
}]
}],
"quantity" : {
"value" : 2
},
"unitPrice" : {
"value" : 5.00,
"currency" : "USD"
},
"factor" : 1.1,
"net" : {
"value" : 11.00,
"currency" : "USD"
}
}]
},
{
"sequence" : 3,
"revenue" : {
"coding" : [{
"system" : "http://terminology.hl7.org/CodeSystem/ex-revenue-center",
"code" : "0010",
"display" : "Vision Clinic"
}]
},
"category" : {
"coding" : [{
"system" : "http://example.org/fhir/CodeSystem/benefit-subcategory",
"code" : "F6",
"display" : "Vision Coverage"
}]
},
"productOrService" : {
"coding" : [{
"system" : "http://example.org/fhir/CodeSystem/ex-visionservice",
"code" : "fst"
}]
},
"unitPrice" : {
"value" : 220.00,
"currency" : "USD"
},
"factor" : 0.07,
"net" : {
"value" : 15.40,
"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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