Release 4 5

This page is part of the FHIR Specification (v4.0.1: R4 (v5.0.0: R5 - Mixed Normative and STU ) ). This is the current published version 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

Claimresponse-example-unsolicited-preauth.ttl

Example ClaimResponse/UR3503 (Turtle)

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

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

Unsolicited Pre-Authorization for social Dental Services 

@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/ClaimResponse/UR3503> a fhir:ClaimResponse;
  fhir:nodeRole fhir:treeRoot;
  fhir:Resource.id [ fhir:value "UR3503"];
  fhir:DomainResource.text [
     fhir:Narrative.status [ fhir:value "generated" ];
     fhir:Narrative.div "<div xmlns=\"http://www.w3.org/1999/xhtml\">A sample unsolicited pre-authorization response which authorizes basic dental services to be performed for a patient.</div>"
  ];
  fhir:ClaimResponse.identifier [
     fhir:index 0;
     fhir:Identifier.system [ fhir:value "http://www.SocialBenefitsInc.com/fhir/ClaimResponse" ];
     fhir:Identifier.value [ fhir:value "UR3503" ]
  ];
  fhir:ClaimResponse.status [ fhir:value "active"];
  fhir:ClaimResponse.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:ClaimResponse.use [ fhir:value "preauthorization"];
  fhir:ClaimResponse.patient [
     fhir:link <http://hl7.org/fhir/Patient/1>;
     fhir:Reference.reference [ fhir:value "Patient/1" ]
  ];
  fhir:ClaimResponse.created [ fhir:value "2014-08-16"^^xsd:date];
  fhir:ClaimResponse.insurer [
     fhir:Reference.identifier [
       fhir:Identifier.system [ fhir:value "http://www.jurisdiction.org/insurers" ];
       fhir:Identifier.value [ fhir:value "444123" ]
     ]
  ];
  fhir:ClaimResponse.requestor [
     fhir:link <http://hl7.org/fhir/Organization/1>;
     fhir:Reference.reference [ fhir:value "Organization/1" ]
  ];
  fhir:ClaimResponse.outcome [ fhir:value "complete"];
  fhir:ClaimResponse.disposition [ fhir:value "The enclosed services are authorized for your provision within 30 days of this notice."];
  fhir:ClaimResponse.preAuthRef [ fhir:value "18SS12345"];
  fhir:ClaimResponse.payeeType [
     fhir:CodeableConcept.coding [
       fhir:index 0;
       fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/payeetype" ];
       fhir:Coding.code [ fhir:value "provider" ]
     ]
  ];
  fhir:ClaimResponse.addItem [
     fhir:index 0;
     fhir:ClaimResponse.addItem.itemSequence [
       fhir:value "1"^^xsd:positiveInteger;
       fhir:index 0
     ];
     fhir:ClaimResponse.addItem.productOrService [
       fhir:CodeableConcept.coding [
         fhir:index 0;
         fhir:Coding.system [ fhir:value "http://example.org/fhir/oralservicecodes" ];
         fhir:Coding.code [ fhir:value "1101" ]
       ]
     ];
     fhir:ClaimResponse.addItem.modifier [
       fhir:index 0;
       fhir:CodeableConcept.coding [
         fhir:index 0;
         fhir:Coding.system [ fhir:value "http://example.org/fhir/modifiers" ];
         fhir:Coding.code [ fhir:value "x" ];
         fhir:Coding.display [ fhir:value "None" ]
       ]
     ];
     fhir:ClaimResponse.addItem.net [
       fhir:Money.value [ fhir:value "250.00"^^xsd:decimal ];
       fhir:Money.currency [ fhir:value "USD" ]
     ];
     fhir:ClaimResponse.addItem.noteNumber [
       fhir:value "101"^^xsd:positiveInteger;
       fhir:index 0
     ];
     fhir:ClaimResponse.addItem.adjudication [
       fhir:index 0;
       fhir:ClaimResponse.item.adjudication.category [
         fhir:CodeableConcept.coding [
           fhir:index 0;
           fhir:Coding.code [ fhir:value "eligible" ]
         ]
       ];
       fhir:ClaimResponse.item.adjudication.amount [
         fhir:Money.value [ fhir:value "250.00"^^xsd:decimal ];
         fhir:Money.currency [ fhir:value "USD" ]

[a fhir:ClaimResponse ;
  fhir:nodeRole fhir:treeRoot ;
  fhir:id [ fhir:v "UR3503"] ; # 
  fhir:text [
     fhir:status [ fhir:v "generated" ] ;
     fhir:div "<div xmlns=\"http://www.w3.org/1999/xhtml\">A sample unsolicited pre-authorization response which authorizes basic dental services to be performed for a patient.</div>"
  ] ; # 
  fhir:identifier ( [
     fhir:system [ fhir:v "http://www.SocialBenefitsInc.com/fhir/ClaimResponse"^^xsd:anyURI ] ;
     fhir:value [ fhir:v "UR3503" ]
  ] ) ; # 
  fhir:status [ fhir:v "active"] ; # 
  fhir:type [
     fhir:coding ( [
       fhir:system [ fhir:v "http://terminology.hl7.org/CodeSystem/claim-type"^^xsd:anyURI ] ;
       fhir:code [ fhir:v "oral" ]
     ] )
  ] ; # 
  fhir:use [ fhir:v "preauthorization"] ; # 
  fhir:patient [
     fhir:reference [ fhir:v "Patient/1" ]
  ] ; #   this is unsolicited therefore no reference to the preauthorization request exists  
  fhir:created [ fhir:v "2014-08-16"^^xsd:date] ; # 
  fhir:insurer [
     fhir:identifier [
       fhir:system [ fhir:v "http://www.jurisdiction.org/insurers"^^xsd:anyURI ] ;
       fhir:value [ fhir:v "444123" ]
     ] #   Social Benefits Inc.  
  ] ; # 
  fhir:requestor [
     fhir:reference [ fhir:v "Organization/1" ]
  ] ; # 
  fhir:outcome [ fhir:v "complete"] ; # 
  fhir:disposition [ fhir:v "The enclosed services are authorized for your provision within 30 days of this notice."] ; # 
  fhir:preAuthRef [ fhir:v "18SS12345"] ; # 
  fhir:payeeType [
     fhir:coding ( [
       fhir:system [ fhir:v "http://terminology.hl7.org/CodeSystem/payeetype"^^xsd:anyURI ] ;
       fhir:code [ fhir:v "provider" ]
     ] ) #   advise that assignment of benefit is allowed  
  ] ; # 
  fhir:addItem ( [
     fhir:itemSequence ( [ fhir:v "1"^^xsd:positiveInteger ] ) ; #   Exam  
     fhir:productOrService [
       fhir:coding ( [
         fhir:system [ fhir:v "http://example.org/fhir/oralservicecodes"^^xsd:anyURI ] ;
         fhir:code [ fhir:v "1101" ]
       ] )
     ] ;
     fhir:modifier ( [
       fhir:coding ( [
         fhir:system [ fhir:v "http://example.org/fhir/modifiers"^^xsd:anyURI ] ;
         fhir:code [ fhir:v "x" ] ;
         fhir:display [ fhir:v "None" ]
       ] )
     ] ) ;
     fhir:net [
       fhir:value [ fhir:v "250.00"^^xsd:decimal ] ;
       fhir:currency [ fhir:v "USD" ] #   net set to same value as the eligible amount. Providers will only be reimbursed to the net\/eligible amount less the co-pay.  
     ] ;
     fhir:noteNumber ( [ fhir:v "101"^^xsd:positiveInteger ] ) ;
     fhir:adjudication ( [
       fhir:category [
         fhir:coding ( [
           fhir:code [ fhir:v "eligible" ]
         ] )
       ] ;
       fhir:amount [
         fhir:value [ fhir:v "250.00"^^xsd:decimal ] ;
         fhir:currency [ fhir:v "USD" ]

       ]
     ], [
       fhir:index 1;
       fhir:ClaimResponse.item.adjudication.category [
         fhir:CodeableConcept.coding [
           fhir:index 0;
           fhir:Coding.code [ fhir:value "copay" ]
         ]
       ];
       fhir:ClaimResponse.item.adjudication.amount [
         fhir:Money.value [ fhir:value "10.00"^^xsd:decimal ];
         fhir:Money.currency [ fhir:value "USD" ]

     ] [
       fhir:category [
         fhir:coding ( [
           fhir:code [ fhir:v "copay" ]
         ] )
       ] ;
       fhir:amount [
         fhir:value [ fhir:v "10.00"^^xsd:decimal ] ;
         fhir:currency [ fhir:v "USD" ]

       ]
     ], [
       fhir:index 2;
       fhir:ClaimResponse.item.adjudication.category [
         fhir:CodeableConcept.coding [
           fhir:index 0;
           fhir:Coding.code [ fhir:value "eligpercent" ]
         ]
       ];
       fhir:ClaimResponse.item.adjudication.value [ fhir:value "100.00"^^xsd:decimal ]
     ], [
       fhir:index 3;
       fhir:ClaimResponse.item.adjudication.category [
         fhir:CodeableConcept.coding [
           fhir:index 0;
           fhir:Coding.code [ fhir:value "benefit" ]
         ]
       ];
       fhir:ClaimResponse.item.adjudication.amount [
         fhir:Money.value [ fhir:value "240.00"^^xsd:decimal ];
         fhir:Money.currency [ fhir:value "USD" ]

     ] [
       fhir:category [
         fhir:coding ( [
           fhir:code [ fhir:v "eligpercent" ]
         ] )
       ] ;
       fhir:quantity [
         fhir:value [ fhir:v "100.00"^^xsd:decimal ]

       ]
     ]
  ], [
     fhir:index 1;
     fhir:ClaimResponse.addItem.itemSequence [
       fhir:value "1"^^xsd:positiveInteger;
       fhir:index 0
     ];
     fhir:ClaimResponse.addItem.productOrService [
       fhir:CodeableConcept.coding [
         fhir:index 0;
         fhir:Coding.system [ fhir:value "http://example.org/fhir/oralservicecodes" ];
         fhir:Coding.code [ fhir:value "2101" ];
         fhir:Coding.display [ fhir:value "Radiograph, series (12)" ]

     ] [
       fhir:category [
         fhir:coding ( [
           fhir:code [ fhir:v "benefit" ]
         ] )
       ] ;
       fhir:amount [
         fhir:value [ fhir:v "240.00"^^xsd:decimal ] ;
         fhir:currency [ fhir:v "USD" ] #   insurer will pay up to this amount.  

       ]
     ];
     fhir:ClaimResponse.addItem.net [
       fhir:Money.value [ fhir:value "800.00"^^xsd:decimal ];
       fhir:Money.currency [ fhir:value "USD" ]
     ];
     fhir:ClaimResponse.addItem.adjudication [
       fhir:index 0;
       fhir:ClaimResponse.item.adjudication.category [
         fhir:CodeableConcept.coding [
           fhir:index 0;
           fhir:Coding.code [ fhir:value "eligible" ]
         ]
       ];
       fhir:ClaimResponse.item.adjudication.amount [
         fhir:Money.value [ fhir:value "800.00"^^xsd:decimal ];
         fhir:Money.currency [ fhir:value "USD" ]

     ] )
  ] [
     fhir:itemSequence ( [ fhir:v "1"^^xsd:positiveInteger ] ) ; #   Xray Panel  
     fhir:productOrService [
       fhir:coding ( [
         fhir:system [ fhir:v "http://example.org/fhir/oralservicecodes"^^xsd:anyURI ] ;
         fhir:code [ fhir:v "2101" ] ;
         fhir:display [ fhir:v "Radiograph, series (12)" ]
       ] )
     ] ;
     fhir:net [
       fhir:value [ fhir:v "800.00"^^xsd:decimal ] ;
       fhir:currency [ fhir:v "USD" ]
     ] ;
     fhir:adjudication ( [
       fhir:category [
         fhir:coding ( [
           fhir:code [ fhir:v "eligible" ]
         ] )
       ] ;
       fhir:amount [
         fhir:value [ fhir:v "800.00"^^xsd:decimal ] ;
         fhir:currency [ fhir:v "USD" ]

       ]
     ], [
       fhir:index 1;
       fhir:ClaimResponse.item.adjudication.category [
         fhir:CodeableConcept.coding [
           fhir:index 0;
           fhir:Coding.code [ fhir:value "eligpercent" ]
         ]
       ];
       fhir:ClaimResponse.item.adjudication.value [ fhir:value "100.00"^^xsd:decimal ]
     ], [
       fhir:index 2;
       fhir:ClaimResponse.item.adjudication.category [
         fhir:CodeableConcept.coding [
           fhir:index 0;
           fhir:Coding.code [ fhir:value "benefit" ]
         ]
       ];
       fhir:ClaimResponse.item.adjudication.amount [
         fhir:Money.value [ fhir:value "800.00"^^xsd:decimal ];
         fhir:Money.currency [ fhir:value "USD" ]

     ] [
       fhir:category [
         fhir:coding ( [
           fhir:code [ fhir:v "eligpercent" ]
         ] )
       ] ;
       fhir:quantity [
         fhir:value [ fhir:v "100.00"^^xsd:decimal ]

       ]
     ]
  ];
  fhir:ClaimResponse.total [
     fhir:index 0;
     fhir:ClaimResponse.total.category [
       fhir:CodeableConcept.coding [
         fhir:index 0;
         fhir:Coding.code [ fhir:value "submitted" ]

     ] [
       fhir:category [
         fhir:coding ( [
           fhir:code [ fhir:v "benefit" ]
         ] )
       ] ;
       fhir:amount [
         fhir:value [ fhir:v "800.00"^^xsd:decimal ] ;
         fhir:currency [ fhir:v "USD" ]

       ]
     ];
     fhir:ClaimResponse.total.amount [
       fhir:Money.value [ fhir:value "1050.00"^^xsd:decimal ];
       fhir:Money.currency [ fhir:value "USD" ]

     ] )
  ] ) ; #   Authorization details  ,   Authorization to receive an exam and an Xray panel  
  fhir:total ( [
     fhir:category [
       fhir:coding ( [
         fhir:code [ fhir:v "submitted" ]
       ] )
     ] ;
     fhir:amount [
       fhir:value [ fhir:v "1050.00"^^xsd:decimal ] ;
       fhir:currency [ fhir:v "USD" ]

     ]
  ], [
     fhir:index 1;
     fhir:ClaimResponse.total.category [
       fhir:CodeableConcept.coding [
         fhir:index 0;
         fhir:Coding.code [ fhir:value "benefit" ]
       ]
     ];
     fhir:ClaimResponse.total.amount [
       fhir:Money.value [ fhir:value "1040.00"^^xsd:decimal ];
       fhir:Money.currency [ fhir:value "USD" ]

  ] [
     fhir:category [
       fhir:coding ( [
         fhir:code [ fhir:v "benefit" ]
       ] )
     ] ;
     fhir:amount [
       fhir:value [ fhir:v "1040.00"^^xsd:decimal ] ;
       fhir:currency [ fhir:v "USD" ]

     ]
  ];
  fhir:ClaimResponse.processNote [
     fhir:index 0;
     fhir:ClaimResponse.processNote.number [ fhir:value "101"^^xsd:positiveInteger ];
     fhir:ClaimResponse.processNote.type [ fhir:value "print" ];
     fhir:ClaimResponse.processNote.text [ fhir:value "Please submit a Pre-Authorization request if a more extensive examination or urgent services are required." ];
     fhir:ClaimResponse.processNote.language [
       fhir:CodeableConcept.coding [
         fhir:index 0;
         fhir:Coding.system [ fhir:value "urn:ietf:bcp:47" ];
         fhir:Coding.code [ fhir:value "en-CA" ]
       ]

  ] ) ; # 
  fhir:processNote ( [
     fhir:number [ fhir:v "101"^^xsd:positiveInteger ] ;
     fhir:type [
       fhir:coding ( [
         fhir:system [ fhir:v "http://hl7.org/fhir/note-type"^^xsd:anyURI ] ;
         fhir:code [ fhir:v "print" ]
       ] )
     ] ;
     fhir:text [ fhir:v "Please submit a Pre-Authorization request if a more extensive examination or urgent services are required." ] ;
     fhir:language [
       fhir:coding ( [
         fhir:system [ fhir:v "urn:ietf:bcp:47"^^xsd:anyURI ] ;
         fhir:code [ fhir:v "en-CA" ]
       ] )

     ]
  ];
  fhir:ClaimResponse.insurance [
     fhir:index 0;
     fhir:ClaimResponse.insurance.sequence [ fhir:value "1"^^xsd:positiveInteger ];
     fhir:ClaimResponse.insurance.focal [ fhir:value "true"^^xsd:boolean ];
     fhir:ClaimResponse.insurance.coverage [
       fhir:link <http://hl7.org/fhir/Coverage/9876B1>;
       fhir:Reference.reference [ fhir:value "Coverage/9876B1" ]

  ] ) ; # 
  fhir:insurance ( [
     fhir:sequence [ fhir:v "1"^^xsd:positiveInteger ] ;
     fhir:focal [ fhir:v "true"^^xsd:boolean ] ;
     fhir:coverage [
       fhir:reference [ fhir:v "Coverage/9876B1" ]

     ]
  ] .

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

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

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

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

<http://hl7.org/fhir/ClaimResponse/UR3503.ttl> a owl:Ontology;
  owl:imports fhir:fhir.ttl;
  owl:versionIRI <http://build.fhir.org/ClaimResponse/UR3503.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.