GAO Ballot Package

This page is part of the FHIR Specification (v1.1.0: STU 3 Ballot 1). 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 R3 R2

This is a frozen snapshot of the FHIR specification created for the purpose of balloting the GAO implementation Guide. It includes draft changes that may be part of the future DSTU 2.1 release but further change is expected. Readers should focus solely on the GAO implementation content, and FHIR DSTU 2 for other purposes.

Claim-example-oral-orthoplan.json

Raw JSON (canonical form)

PreAuthorization with Orthodontic Treatment Plan

{
  "resourceType": "Claim",
  "id": "100153",
  "text": {
    "status": "generated",
    "div": "<div>A human-readable rendering of the Oral Health Claim</div>"
  },
  "type": "oral",
  "identifier": [
    {
      "system": "http://happyvalley.com/claim",
      "value": "12355"
    }
  ],
  "created": "2015-03-16",
  "target": {
    "reference": "Organization/2"
  },
  "organization": {
    "reference": "Organization/1"
  },
  "use": "proposed",
  "priority": {
    "code": "normal"
  },
  "payee": {
    "type": {
      "code": "provider"
    }
  },
  "diagnosis": [
    {
      "sequence": 1,
      "diagnosis": {
        "system": "http://hl7.org/fhir/sid/icd-10",
        "code": "123457"
      }
    }
  ],
  "patient": {
    "reference": "Patient/1"
  },
  "coverage": [
    {
      "sequence": 1,
      "focal": true,
      "coverage": {
        "reference": "Coverage/9876B1"
      },
      "relationship": {
        "code": "self"
      }
    }
  ],
  "item": [
    {
      "sequence": 1,
      "type": {
        "fhir_comments": [
          "  was group changed by GG to be valid  "
        ],
        "system": "http://hl7.org/fhir/v3/ActCode",
        "code": "FRAMEING"
      },
      "provider": {
        "reference": "Practitioner/example"
      },
      "diagnosisLinkId": [
        1
      ],
      "service": {
        "system": "http://hl7.org/fhir/oralservicecodes",
        "code": "ORTHPLAN"
      },
      "serviceDate": "2015-05-16",
      "unitPrice": {
        "fhir_comments": [
          "  Start Date  "
        ],
        "value": 9000.00,
        "system": "urn:iso:std:iso:4217",
        "code": "USD"
      },
      "net": {
        "value": 9000.00,
        "system": "urn:iso:std:iso:4217",
        "code": "USD"
      },
      "detail": [
        {
          "sequence": 1,
          "type": {
            "fhir_comments": [
              "  Exam Fee  ",
              "  was service, changed by GG to be valid  "
            ],
            "system": "http://hl7.org/fhir/v3/ActCode",
            "code": "CSINV"
          },
          "service": {
            "system": "http://hl7.org/fhir/oralservicecodes",
            "code": "ORTHOEXAM"
          },
          "unitPrice": {
            "value": 1000.00,
            "system": "urn:iso:std:iso:4217",
            "code": "USD"
          },
          "net": {
            "value": 1000.00,
            "system": "urn:iso:std:iso:4217",
            "code": "USD"
          }
        },
        {
          "sequence": 2,
          "type": {
            "fhir_comments": [
              "  Diagnostic Fee  ",
              "  was service, changed by GG to be valid  "
            ],
            "system": "http://hl7.org/fhir/v3/ActCode",
            "code": "CSINV"
          },
          "service": {
            "system": "http://hl7.org/fhir/oralservicecodes",
            "code": "ORTHODIAG"
          },
          "unitPrice": {
            "value": 1500.00,
            "system": "urn:iso:std:iso:4217",
            "code": "USD"
          },
          "net": {
            "value": 1500.00,
            "system": "urn:iso:std:iso:4217",
            "code": "USD"
          }
        },
        {
          "sequence": 3,
          "type": {
            "fhir_comments": [
              "  Initial Payment  ",
              "  was service, changed by GG to be valid  "
            ],
            "system": "http://hl7.org/fhir/v3/ActCode",
            "code": "CSINV"
          },
          "service": {
            "system": "http://hl7.org/fhir/oralservicecodes",
            "code": "ORTHOINITIAL"
          },
          "unitPrice": {
            "value": 500.00,
            "system": "urn:iso:std:iso:4217",
            "code": "USD"
          },
          "net": {
            "value": 500.00,
            "system": "urn:iso:std:iso:4217",
            "code": "USD"
          }
        },
        {
          "sequence": 4,
          "type": {
            "fhir_comments": [
              "  Duration in Months  ",
              "  was service, changed by GG to be valid  "
            ],
            "system": "http://hl7.org/fhir/v3/ActCode",
            "code": "CSINV"
          },
          "service": {
            "system": "http://hl7.org/fhir/oralservicecodes",
            "code": "ORTHOMONTHS"
          },
          "quantity": {
            "value": 24
          }
        },
        {
          "sequence": 5,
          "type": {
            "fhir_comments": [
              "  Periodic Payments  ",
              "  was service, changed by GG to be valid  "
            ],
            "system": "http://hl7.org/fhir/v3/ActCode",
            "code": "CSINV"
          },
          "service": {
            "system": "http://hl7.org/fhir/oralservicecodes",
            "code": "ORTHOPERIODIC"
          },
          "quantity": {
            "value": 24
          },
          "unitPrice": {
            "value": 250.00,
            "system": "urn:iso:std:iso:4217",
            "code": "USD"
          },
          "net": {
            "value": 250.00,
            "system": "urn:iso:std:iso:4217",
            "code": "USD"
          }
        }
      ]
    },
    {
      "sequence": 2,
      "type": {
        "code": "service"
      },
      "provider": {
        "reference": "Practitioner/example"
      },
      "service": {
        "system": "http://hl7.org/fhir/oralservicecodes",
        "code": "21211"
      },
      "serviceDate": "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"
      },
      "subSite": [
        {
          "system": "http://fdi.org/fhir/oralsurfacecodes",
          "code": "L"
        }
      ]
    },
    {
      "sequence": 3,
      "type": {
        "code": "group"
      },
      "provider": {
        "reference": "Practitioner/example"
      },
      "service": {
        "system": "http://hl7.org/fhir/oralservicecodes",
        "code": "27211"
      },
      "serviceDate": "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"
      },
      "detail": [
        {
          "sequence": 1,
          "type": {
            "code": "service"
          },
          "service": {
            "system": "http://hl7.org/fhir/oralservicecodes",
            "code": "27211"
          },
          "unitPrice": {
            "value": 750.00,
            "system": "urn:iso:std:iso:4217",
            "code": "USD"
          },
          "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"
          },
          "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.