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

Claimresponse-example.ttl

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General Person Primary Coverage Example

@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//ClaimResponse/R3500> a fhir:ClaimResponse;
  fhir:nodeRole fhir:treeRoot;
  fhir:Resource.id [ fhir:value "R3500"];
  fhir:DomainResource.text [
     fhir:Narrative.status [ fhir:value "generated" ]
  ];
  fhir:ClaimResponse.identifier [
     fhir:index 0;
     fhir:Identifier.system [ fhir:value "http://www.BenefitsInc.com/fhir/remittance" ];
     fhir:Identifier.value [ fhir:value "R3500" ]
  ];
  fhir:ClaimResponse.requestReference [
     fhir:reference <http://www.BenefitsInc.com/fhir/oralhealthclaim/15476332402>;
     fhir:Reference.reference [ fhir:value "http://www.BenefitsInc.com/fhir/oralhealthclaim/15476332402" ]
  ];
  fhir:ClaimResponse.created [ fhir:value "2014-08-16"^^xs:date];
  fhir:ClaimResponse.organizationIdentifier [
     fhir:Identifier.system [ fhir:value "http://www.jurisdiction.org/insurers" ];
     fhir:Identifier.value [ fhir:value "555123" ]
  ];
  fhir:ClaimResponse.outcome [ fhir:value "complete"];
  fhir:ClaimResponse.disposition [ fhir:value "Claim settled as per contract."];
  fhir:ClaimResponse.payeeType [
     fhir:Coding.system [ fhir:value "http://hl7.org/fhir/payeetype" ];
     fhir:Coding.code [ fhir:value "provider" ]
  ];
  fhir:ClaimResponse.item [
     fhir:index 0;
     fhir:ClaimResponse.item.sequenceLinkId [ fhir:value "1"^^xs:int ];
     fhir:ClaimResponse.item.adjudication [
       fhir:index 0;
       fhir:ClaimResponse.item.adjudication.category [
         fhir:Coding.code [ fhir:value "eligible" ]       ];
       fhir:ClaimResponse.item.adjudication.amount [
         fhir:Quantity.value [ fhir:value "135.57"^^xs:decimal ];
         fhir:Quantity.system [ fhir:value "urn:iso:std:iso:4217" ];
         fhir:Quantity.code [ fhir:value "USD" ]       ]     ];
     fhir:ClaimResponse.item.adjudication [
       fhir:index 1;
       fhir:ClaimResponse.item.adjudication.category [
         fhir:Coding.code [ fhir:value "copay" ]       ];
       fhir:ClaimResponse.item.adjudication.amount [
         fhir:Quantity.value [ fhir:value "10.00"^^xs:decimal ];
         fhir:Quantity.system [ fhir:value "urn:iso:std:iso:4217" ];
         fhir:Quantity.code [ fhir:value "USD" ]       ]     ];
     fhir:ClaimResponse.item.adjudication [
       fhir:index 2;
       fhir:ClaimResponse.item.adjudication.category [
         fhir:Coding.code [ fhir:value "eligpercent" ]       ];
       fhir:ClaimResponse.item.adjudication.value [ fhir:value "80.00"^^xs:decimal ]     ];
     fhir:ClaimResponse.item.adjudication [
       fhir:index 3;
       fhir:ClaimResponse.item.adjudication.category [
         fhir:Coding.code [ fhir:value "benefit" ]       ];
       fhir:ClaimResponse.item.adjudication.amount [
         fhir:Quantity.value [ fhir:value "100.47"^^xs:decimal ];
         fhir:Quantity.system [ fhir:value "urn:iso:std:iso:4217" ];
         fhir:Quantity.code [ fhir:value "USD" ]       ]     ]
  ];
  fhir:ClaimResponse.totalCost [
     fhir:Quantity.value [ fhir:value "135.57"^^xs:decimal ];
     fhir:Quantity.system [ fhir:value "urn:iso:std:iso:4217" ];
     fhir:Quantity.code [ fhir:value "USD" ]
  ];
  fhir:ClaimResponse.totalBenefit [
     fhir:Quantity.value [ fhir:value "100.47"^^xs:decimal ];
     fhir:Quantity.system [ fhir:value "urn:iso:std:iso:4217" ];
     fhir:Quantity.code [ fhir:value "USD" ]
  ];
  fhir:ClaimResponse.paymentDate [ fhir:value "2014-08-31"^^xs:date];
  fhir:ClaimResponse.paymentAmount [
     fhir:Quantity.value [ fhir:value "100.47"^^xs:decimal ];
     fhir:Quantity.system [ fhir:value "urn:iso:std:iso:4217" ];
     fhir:Quantity.code [ fhir:value "USD" ]
  ];
  fhir:ClaimResponse.paymentRef [
     fhir:Identifier.system [ fhir:value "http://www.BenefitsInc.com/fhir/paymentRef" ];
     fhir:Identifier.value [ fhir:value "201408-2-1569478" ]
  ].

# -------------------------------------------------------------------------------------

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.