STU 3 Candidate
This page is part of the FHIR Specification (v1.4.0: STU 3 Ballot 3). The current version which supercedes this version is 5.0.0. For a full list of available versions, see the Directory of published versions 
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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",
"targetReference": {
"reference": "Organization/2"
},
"organizationReference": {
"reference": "Organization/1"
},
"use": "proposed",
"priority": {
"code": "normal"
},
"fundsReserve": {
"code": "provider"
},
"payee": {
"type": {
"code": "provider"
}
},
"diagnosis": [
{
"sequence": 1,
"diagnosis": {
"system": "http://hl7.org/fhir/sid/icd-10",
"code": "123457"
}
}
],
"patientReference": {
"reference": "Patient/1"
},
"coverage": [
{
"sequence": 1,
"focal": true,
"coverageReference": {
"reference": "Coverage/9876B1"
}
}
],
"item": [
{
"sequence": 1,
"type": {
"fhir_comments": [
" was group changed by GG to be valid "
],
"system": "http://hl7.org/fhir/v3/ActCode",
"code": "FRAMEING"
},
"providerReference": {
"reference": "Practitioner/example"
},
"diagnosisLinkId": [
1
],
"service": {
"system": "http://hl7.org/fhir/oralservicecodes",
"code": "ORTHPLAN"
},
"servicedDate": "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"
},
"providerReference": {
"reference": "Practitioner/example"
},
"service": {
"system": "http://hl7.org/fhir/oralservicecodes",
"code": "21211"
},
"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"
},
"subSite": [
{
"system": "http://fdi.org/fhir/oralsurfacecodes",
"code": "L"
}
]
},
{
"sequence": 3,
"type": {
"code": "group"
},
"providerReference": {
"reference": "Practitioner/example"
},
"service": {
"system": "http://hl7.org/fhir/oralservicecodes",
"code": "27211"
},
"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"
},
"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.
© HL7.org 2011+. FHIR STU3 Candidate (v1.4.0-8139) generated on Thu, Mar 31, 2016 08:08+1100. QA Page
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