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(v3.0.2:
STU
2).
3).
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R2
| Financial Management Work Group | Maturity Level : N/A | Ballot Status : Informative | Compartments : Encounter , Patient , Practitioner , RelatedPerson |
Average dental Claim with Information (Missing Teeth and Student)
Financial
{
"resourceType": "Claim",
"id": "100151",
"text": {
"status": "generated",
"div": "<div>A human-readable rendering of the Oral Health Claim</div>"
"div": "<div xmlns=\"http://www.w3.org/1999/xhtml\">A human-readable rendering of the Oral Health Claim</div>"
},
"type": "oral",
"identifier": [
{
"system": "http://happyvalley.com/claim",
"value": "12346"
}
],
"status": "active",
"type": {
"coding": [
{
"system": "http://hl7.org/fhir/ex-claimtype",
"code": "oral"
}
]
},
"use": "complete",
"patient": {
"reference": "Patient/1"
},
"created": "2014-08-16",
"target": {
"insurer": {
"reference": "Organization/2"
},
"organization": {
"reference": "Organization/1"
},
"use": "complete",
"priority": {
"code": "normal"
"coding": [
{
"code": "normal"
}
]
},
"payee": {
"type": {
"code": "provider"
"coding": [
{
"code": "provider"
}
]
}
},
"careTeam": [
{
"sequence": 1,
"provider": {
"reference": "Practitioner/example"
}
}
],
"information": [
{
"sequence": 1,
"category": {
"coding": [
{
"system": "http://hl7.org/fhir/claiminformationcategory",
"code": "missingtooth"
}
]
},
"code": {
"coding": [
{
"system": "http://hl7.org/fhir/ex-tooth",
"code": "15"
}
]
},
"timingDate": "2012-04-07",
"reason": {
"coding": [
{
"system": "http://hl7.org/fhir/missingtoothreason",
"code": "e"
}
]
}
},
{
"sequence": 2,
"category": {
"coding": [
{
"system": "http://hl7.org/fhir/claiminformationcategory",
"code": "exception"
}
]
},
"code": {
"coding": [
{
"system": "http://hl7.org/fhir/claim-exception",
"code": "student"
}
]
},
"valueString": "Happy Valley Community College"
}
],
"diagnosis": [
{
"sequence": 1,
"diagnosis": {
"code": "123456"
"diagnosisCodeableConcept": {
"coding": [
{
"code": "123456"
}
]
}
}
],
"patient": {
"reference": "Patient/1"
},
"coverage": [
"insurance": [
{
"sequence": 1,
"focal": true,
"coverage": {
"reference": "Coverage/9876B1"
},
"relationship": {
"code": "self"
}
}
],
"item": [
{
"sequence": 1,
"type": {
"code": "service"
},
"provider": {
"reference": "Practitioner/example"
},
"careTeamLinkId": [
1
],
"service": {
"system": "http://hl7.org/fhir/oralservicecodes",
"code": "1200"
"coding": [
{
"system": "http://example.org/fhir/oralservicecodes",
"code": "1200"
}
]
},
"serviceDate": "2014-08-16",
"servicedDate": "2014-08-16",
"unitPrice": {
"value": 135.57,
"system": "urn:iso:std:iso:4217",
"code": "USD"
},
"net": {
"value": 135.57,
"system": "urn:iso:std:iso:4217",
"code": "USD"
}
},
{
"sequence": 2,
"type": {
"code": "service"
},
"provider": {
"reference": "Practitioner/example"
},
"careTeamLinkId": [
1
],
"service": {
"system": "http://hl7.org/fhir/oralservicecodes",
"code": "21211"
"coding": [
{
"system": "http://example.org/fhir/oralservicecodes",
"code": "21211"
}
]
},
"serviceDate": "2014-08-16",
"servicedDate": "2014-08-16",
"unitPrice": {
"value": 105.00,
"system": "urn:iso:std:iso:4217",
"code": "USD"
},
"net": {
"value": 105.00,
"system": "urn:iso:std:iso:4217",
"code": "USD"
},
"bodySite": {
"system": "http://fdi.org/fhir/oraltoothcodes",
"code": "21"
"coding": [
{
"system": "http://fdi.org/fhir/oraltoothcodes",
"code": "21"
}
]
},
"subSite": [
{
"system": "http://fdi.org/fhir/oralsurfacecodes",
"code": "L"
"coding": [
{
"system": "http://fdi.org/fhir/oralsurfacecodes",
"code": "L"
}
]
}
]
},
{
"sequence": 3,
"type": {
"code": "group"
},
"provider": {
"reference": "Practitioner/example"
},
"careTeamLinkId": [
1
],
"service": {
"system": "http://hl7.org/fhir/oralservicecodes",
"code": "27211"
"coding": [
{
"system": "http://example.org/fhir/oralservicecodes",
"code": "27211"
}
]
},
"serviceDate": "2014-08-16",
"servicedDate": "2014-08-16",
"unitPrice": {
"value": 1100.00,
"system": "urn:iso:std:iso:4217",
"code": "USD"
},
"net": {
"value": 1100.00,
"system": "urn:iso:std:iso:4217",
"code": "USD"
},
"bodySite": {
"system": "http://fdi.org/fhir/oraltoothcodes",
"code": "36"
"coding": [
{
"system": "http://fdi.org/fhir/oraltoothcodes",
"code": "36"
}
]
},
"detail": [
{
"sequence": 1,
"type": {
"code": "service"
},
"service": {
"system": "http://hl7.org/fhir/oralservicecodes",
"code": "27211"
"coding": [
{
"system": "http://example.org/fhir/oralservicecodes",
"code": "27211"
}
]
},
"unitPrice": {
"value": 750.00,
"value": 1000.00,
"system": "urn:iso:std:iso:4217",
"code": "USD"
},
"factor": 0.75,
"net": {
"value": 750.00,
"system": "urn:iso:std:iso:4217",
"code": "USD"
}
},
{
"sequence": 2,
"type": {
"code": "service"
},
"service": {
"system": "http://hl7.org/fhir/oralservicecodes",
"code": "lab"
"coding": [
{
"system": "http://example.org/fhir/oralservicecodes",
"code": "lab"
}
]
},
"unitPrice": {
"value": 350.00,
"system": "urn:iso:std:iso:4217",
"code": "USD"
},
"net": {
"value": 350.00,
"system": "urn:iso:std:iso:4217",
"code": "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
DSTU2
(v1.0.2-7202)
Release
3
(STU;
v3.0.2-11200)
generated
on
Sat,
Thurs,
Oct
24,
2015
07:44+1100.
2019
11:53+1100.
QA
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