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 . Page versions: R5 R4B R4 R3

Claim-example-oral-orthoplan.ttl

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PreAuthorization with Orthodontic Treatment Plan

@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 xs: <http://www.w3.org/2001/XMLSchema#> .

# - resource -------------------------------------------------------------------

<http://hl7.org/fhir//Claim/100153> a fhir:Claim;
  fhir:nodeRole fhir:treeRoot;
  fhir:Resource.id [ fhir:value "100153"];
  fhir:DomainResource.text [
     fhir:Narrative.status [ fhir:value "generated" ]
  ];
  fhir:Claim.type [ fhir:value "oral"];
  fhir:Claim.identifier [
     fhir:index 0;
     fhir:Identifier.system [ fhir:value "http://happyvalley.com/claim" ];
     fhir:Identifier.value [ fhir:value "12355" ]
  ];
  fhir:Claim.created [ fhir:value "2015-03-16"^^xs:date];
  fhir:Claim.targetReference [
     fhir:reference <http://hl7.org/fhir/Organization/2>;
     fhir:Reference.reference [ fhir:value "Organization/2" ]
  ];
  fhir:Claim.organizationReference [
     fhir:reference <http://hl7.org/fhir/Organization/1>;
     fhir:Reference.reference [ fhir:value "Organization/1" ]
  ];
  fhir:Claim.use [ fhir:value "proposed"];
  fhir:Claim.priority [
     fhir:Coding.code [ fhir:value "normal" ]
  ];
  fhir:Claim.fundsReserve [
     fhir:Coding.code [ fhir:value "provider" ]
  ];
  fhir:Claim.payee [
     fhir:Claim.payee.type [
       fhir:Coding.code [ fhir:value "provider" ]     ]
  ];
  fhir:Claim.diagnosis [
     fhir:index 0;
     fhir:Claim.diagnosis.sequence [ fhir:value "1"^^xs:int ];
     fhir:Claim.diagnosis.diagnosis [
       fhir:Coding.system [ fhir:value "http://hl7.org/fhir/sid/icd-10" ];
       fhir:Coding.code [ fhir:value "123457" ]     ]
  ];
  fhir:Claim.patientReference [
     fhir:reference <http://hl7.org/fhir/Patient/1>;
     fhir:Reference.reference [ fhir:value "Patient/1" ]
  ];
  fhir:Claim.coverage [
     fhir:index 0;
     fhir:Claim.coverage.sequence [ fhir:value "1"^^xs:int ];
     fhir:Claim.coverage.focal [ fhir:value "true"^^xs:boolean ];
     fhir:Claim.coverage.coverageReference [
       fhir:reference <http://hl7.org/fhir/Coverage/9876B1>;
       fhir:Reference.reference [ fhir:value "Coverage/9876B1" ]     ]
  ];
  fhir:Claim.item [
     fhir:index 0;
     fhir:Claim.item.sequence [ fhir:value "1"^^xs:int ];
     fhir:Claim.item.type [
       fhir:Coding.system [ fhir:value "http://hl7.org/fhir/v3/ActCode" ];
       fhir:Coding.code [ fhir:value "FRAMEING" ]     ];
     fhir:Claim.item.providerReference [
       fhir:reference <http://hl7.org/fhir/Practitioner/example>;
       fhir:Reference.reference [ fhir:value "Practitioner/example" ]     ];
     fhir:Claim.item.diagnosisLinkId [
       fhir:value "1"^^xs:int;
       fhir:index 0     ];
     fhir:Claim.item.service [
       fhir:Coding.system [ fhir:value "http://hl7.org/fhir/oralservicecodes" ];
       fhir:Coding.code [ fhir:value "ORTHPLAN" ]     ];
     fhir:Claim.item.servicedDate [ fhir:value "2015-05-16"^^xs:date ];
     fhir:Claim.item.unitPrice [
       fhir:Quantity.value [ fhir:value "9000.00"^^xs:decimal ];
       fhir:Quantity.system [ fhir:value "urn:iso:std:iso:4217" ];
       fhir:Quantity.code [ fhir:value "USD" ]     ];
     fhir:Claim.item.net [
       fhir:Quantity.value [ fhir:value "9000.00"^^xs:decimal ];
       fhir:Quantity.system [ fhir:value "urn:iso:std:iso:4217" ];
       fhir:Quantity.code [ fhir:value "USD" ]     ];
     fhir:Claim.item.detail [
       fhir:index 0;
       fhir:Claim.item.detail.sequence [ fhir:value "1"^^xs:int ];
       fhir:Claim.item.detail.type [
         fhir:Coding.system [ fhir:value "http://hl7.org/fhir/v3/ActCode" ];
         fhir:Coding.code [ fhir:value "CSINV" ]       ];
       fhir:Claim.item.detail.service [
         fhir:Coding.system [ fhir:value "http://hl7.org/fhir/oralservicecodes" ];
         fhir:Coding.code [ fhir:value "ORTHOEXAM" ]       ];
       fhir:Claim.item.detail.unitPrice [
         fhir:Quantity.value [ fhir:value "1000.00"^^xs:decimal ];
         fhir:Quantity.system [ fhir:value "urn:iso:std:iso:4217" ];
         fhir:Quantity.code [ fhir:value "USD" ]       ];
       fhir:Claim.item.detail.net [
         fhir:Quantity.value [ fhir:value "1000.00"^^xs:decimal ];
         fhir:Quantity.system [ fhir:value "urn:iso:std:iso:4217" ];
         fhir:Quantity.code [ fhir:value "USD" ]       ]     ];
     fhir:Claim.item.detail [
       fhir:index 1;
       fhir:Claim.item.detail.sequence [ fhir:value "2"^^xs:int ];
       fhir:Claim.item.detail.type [
         fhir:Coding.system [ fhir:value "http://hl7.org/fhir/v3/ActCode" ];
         fhir:Coding.code [ fhir:value "CSINV" ]       ];
       fhir:Claim.item.detail.service [
         fhir:Coding.system [ fhir:value "http://hl7.org/fhir/oralservicecodes" ];
         fhir:Coding.code [ fhir:value "ORTHODIAG" ]       ];
       fhir:Claim.item.detail.unitPrice [
         fhir:Quantity.value [ fhir:value "1500.00"^^xs:decimal ];
         fhir:Quantity.system [ fhir:value "urn:iso:std:iso:4217" ];
         fhir:Quantity.code [ fhir:value "USD" ]       ];
       fhir:Claim.item.detail.net [
         fhir:Quantity.value [ fhir:value "1500.00"^^xs:decimal ];
         fhir:Quantity.system [ fhir:value "urn:iso:std:iso:4217" ];
         fhir:Quantity.code [ fhir:value "USD" ]       ]     ];
     fhir:Claim.item.detail [
       fhir:index 2;
       fhir:Claim.item.detail.sequence [ fhir:value "3"^^xs:int ];
       fhir:Claim.item.detail.type [
         fhir:Coding.system [ fhir:value "http://hl7.org/fhir/v3/ActCode" ];
         fhir:Coding.code [ fhir:value "CSINV" ]       ];
       fhir:Claim.item.detail.service [
         fhir:Coding.system [ fhir:value "http://hl7.org/fhir/oralservicecodes" ];
         fhir:Coding.code [ fhir:value "ORTHOINITIAL" ]       ];
       fhir:Claim.item.detail.unitPrice [
         fhir:Quantity.value [ fhir:value "500.00"^^xs:decimal ];
         fhir:Quantity.system [ fhir:value "urn:iso:std:iso:4217" ];
         fhir:Quantity.code [ fhir:value "USD" ]       ];
       fhir:Claim.item.detail.net [
         fhir:Quantity.value [ fhir:value "500.00"^^xs:decimal ];
         fhir:Quantity.system [ fhir:value "urn:iso:std:iso:4217" ];
         fhir:Quantity.code [ fhir:value "USD" ]       ]     ];
     fhir:Claim.item.detail [
       fhir:index 3;
       fhir:Claim.item.detail.sequence [ fhir:value "4"^^xs:int ];
       fhir:Claim.item.detail.type [
         fhir:Coding.system [ fhir:value "http://hl7.org/fhir/v3/ActCode" ];
         fhir:Coding.code [ fhir:value "CSINV" ]       ];
       fhir:Claim.item.detail.service [
         fhir:Coding.system [ fhir:value "http://hl7.org/fhir/oralservicecodes" ];
         fhir:Coding.code [ fhir:value "ORTHOMONTHS" ]       ];
       fhir:Claim.item.detail.quantity [
         fhir:Quantity.value [ fhir:value "24"^^xs:decimal ]       ]     ];
     fhir:Claim.item.detail [
       fhir:index 4;
       fhir:Claim.item.detail.sequence [ fhir:value "5"^^xs:int ];
       fhir:Claim.item.detail.type [
         fhir:Coding.system [ fhir:value "http://hl7.org/fhir/v3/ActCode" ];
         fhir:Coding.code [ fhir:value "CSINV" ]       ];
       fhir:Claim.item.detail.service [
         fhir:Coding.system [ fhir:value "http://hl7.org/fhir/oralservicecodes" ];
         fhir:Coding.code [ fhir:value "ORTHOPERIODIC" ]       ];
       fhir:Claim.item.detail.quantity [
         fhir:Quantity.value [ fhir:value "24"^^xs:decimal ]       ];
       fhir:Claim.item.detail.unitPrice [
         fhir:Quantity.value [ fhir:value "250.00"^^xs:decimal ];
         fhir:Quantity.system [ fhir:value "urn:iso:std:iso:4217" ];
         fhir:Quantity.code [ fhir:value "USD" ]       ];
       fhir:Claim.item.detail.net [
         fhir:Quantity.value [ fhir:value "250.00"^^xs:decimal ];
         fhir:Quantity.system [ fhir:value "urn:iso:std:iso:4217" ];
         fhir:Quantity.code [ fhir:value "USD" ]       ]     ]
  ];
  fhir:Claim.item [
     fhir:index 1;
     fhir:Claim.item.sequence [ fhir:value "2"^^xs:int ];
     fhir:Claim.item.type [
       fhir:Coding.code [ fhir:value "service" ]     ];
     fhir:Claim.item.providerReference [
       fhir:reference <http://hl7.org/fhir/Practitioner/example>;
       fhir:Reference.reference [ fhir:value "Practitioner/example" ]     ];
     fhir:Claim.item.service [
       fhir:Coding.system [ fhir:value "http://hl7.org/fhir/oralservicecodes" ];
       fhir:Coding.code [ fhir:value "21211" ]     ];
     fhir:Claim.item.servicedDate [ fhir:value "2014-08-16"^^xs:date ];
     fhir:Claim.item.unitPrice [
       fhir:Quantity.value [ fhir:value "105.00"^^xs:decimal ];
       fhir:Quantity.system [ fhir:value "urn:iso:std:iso:4217" ];
       fhir:Quantity.code [ fhir:value "USD" ]     ];
     fhir:Claim.item.net [
       fhir:Quantity.value [ fhir:value "105.00"^^xs:decimal ];
       fhir:Quantity.system [ fhir:value "urn:iso:std:iso:4217" ];
       fhir:Quantity.code [ fhir:value "USD" ]     ];
     fhir:Claim.item.bodySite [
       fhir:Coding.system [ fhir:value "http://fdi.org/fhir/oraltoothcodes" ];
       fhir:Coding.code [ fhir:value "21" ]     ];
     fhir:Claim.item.subSite [
       fhir:index 0;
       fhir:Coding.system [ fhir:value "http://fdi.org/fhir/oralsurfacecodes" ];
       fhir:Coding.code [ fhir:value "L" ]     ]
  ];
  fhir:Claim.item [
     fhir:index 2;
     fhir:Claim.item.sequence [ fhir:value "3"^^xs:int ];
     fhir:Claim.item.type [
       fhir:Coding.code [ fhir:value "group" ]     ];
     fhir:Claim.item.providerReference [
       fhir:reference <http://hl7.org/fhir/Practitioner/example>;
       fhir:Reference.reference [ fhir:value "Practitioner/example" ]     ];
     fhir:Claim.item.service [
       fhir:Coding.system [ fhir:value "http://hl7.org/fhir/oralservicecodes" ];
       fhir:Coding.code [ fhir:value "27211" ]     ];
     fhir:Claim.item.servicedDate [ fhir:value "2014-08-16"^^xs:date ];
     fhir:Claim.item.unitPrice [
       fhir:Quantity.value [ fhir:value "1100.00"^^xs:decimal ];
       fhir:Quantity.system [ fhir:value "urn:iso:std:iso:4217" ];
       fhir:Quantity.code [ fhir:value "USD" ]     ];
     fhir:Claim.item.net [
       fhir:Quantity.value [ fhir:value "1100.00"^^xs:decimal ];
       fhir:Quantity.system [ fhir:value "urn:iso:std:iso:4217" ];
       fhir:Quantity.code [ fhir:value "USD" ]     ];
     fhir:Claim.item.bodySite [
       fhir:Coding.system [ fhir:value "http://fdi.org/fhir/oraltoothcodes" ];
       fhir:Coding.code [ fhir:value "36" ]     ];
     fhir:Claim.item.detail [
       fhir:index 0;
       fhir:Claim.item.detail.sequence [ fhir:value "1"^^xs:int ];
       fhir:Claim.item.detail.type [
         fhir:Coding.code [ fhir:value "service" ]       ];
       fhir:Claim.item.detail.service [
         fhir:Coding.system [ fhir:value "http://hl7.org/fhir/oralservicecodes" ];
         fhir:Coding.code [ fhir:value "27211" ]       ];
       fhir:Claim.item.detail.unitPrice [
         fhir:Quantity.value [ fhir:value "750.00"^^xs:decimal ];
         fhir:Quantity.system [ fhir:value "urn:iso:std:iso:4217" ];
         fhir:Quantity.code [ fhir:value "USD" ]       ];
       fhir:Claim.item.detail.net [
         fhir:Quantity.value [ fhir:value "750.00"^^xs:decimal ];
         fhir:Quantity.system [ fhir:value "urn:iso:std:iso:4217" ];
         fhir:Quantity.code [ fhir:value "USD" ]       ]     ];
     fhir:Claim.item.detail [
       fhir:index 1;
       fhir:Claim.item.detail.sequence [ fhir:value "2"^^xs:int ];
       fhir:Claim.item.detail.type [
         fhir:Coding.code [ fhir:value "service" ]       ];
       fhir:Claim.item.detail.service [
         fhir:Coding.system [ fhir:value "http://hl7.org/fhir/oralservicecodes" ];
         fhir:Coding.code [ fhir:value "lab" ]       ];
       fhir:Claim.item.detail.unitPrice [
         fhir:Quantity.value [ fhir:value "350.00"^^xs:decimal ];
         fhir:Quantity.system [ fhir:value "urn:iso:std:iso:4217" ];
         fhir:Quantity.code [ fhir:value "USD" ]       ];
       fhir:Claim.item.detail.net [
         fhir:Quantity.value [ fhir:value "350.00"^^xs:decimal ];
         fhir:Quantity.system [ fhir:value "urn:iso:std:iso:4217" ];
         fhir:Quantity.code [ fhir:value "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.