Claim-example-oral-contained.json

SOA Dental Claim (Contained)

{
  "resourceType": "Claim",
  "id": "100152",
  "text": {
    "status": "generated",
    "div": "<div xmlns=\"http://www.w3.org/1999/xhtml\">A human-readable rendering of the Oral Health Claim</div>"
  },
  "contained": [
    {
      "resourceType": "Organization",
      "id": "org-insurer",
      "identifier": [
        {
          "system": "http://www.bindb.com/bin",
          "value": "123456"
        }
      ]
    },
    {
      "resourceType": "Organization",
      "id": "org-org",
      "identifier": [
        {
          "system": "http://www.jurisdiction.com/oralhealthoffices",
          "value": "3456"
        }
      ]
    },
    {
      "resourceType": "Practitioner",
      "id": "provider-1",
      "identifier": [
        {
          "system": "http://www.jurisdiction.com/oralhealthproviders",
          "value": "123456789"
        }
      ]
    },
    {
      "resourceType": "Patient",
      "id": "patient-1",
      "name": [
        {
          "use": "official",
          "family": "Donald",
          "given": [
            "Duck"
          ]
        }
      ],
      "gender": "male",
      "birthDate": "1986-05-17",
      "address": [
        {
          "use": "home",
          "line": [
            "1234 Main Street"
          ],
          "city": "Vancouver",
          "postalCode": "V2H1Y3",
          "country": "CAD"
        }
      ]
    },
    {
      "resourceType": "Coverage",
      "id": "coverage-1",
      "identifier": [
        {
          "system": "http://benefitsinc.com/certificate",
          "value": "12345"
        }
      ],
      "status": "active",
      "type": {
        "coding": [
          {
            "system": "http://hl7.org/fhir/v3/ActCode",
            "code": "EHCPOL"
          }
        ]
      },
      "subscriber": {
        "reference": "#patient-1"
      },
      "beneficiary": {
        "reference": "#patient-1"
      },
      "relationship": {
        "coding": [
          {
            "code": "self"
          }
        ]
      },
      "payor": [
        {
          "identifier": {
            "system": "http://www.bindb.com/bin",
            "value": "123456"
          }
        }
      ],
      "group": {
        "plan": "CBI35",
        "planDisplay": "Corporate Baker's Inc. Plan#35",
        "subPlan": "123",
        "subPlanDisplay": "Trainee Part-time Benefits"
      },
      "dependent": "1",
      "sequence": "1"
    }
  ],
  "identifier": [
    {
      "system": "http://happyvalley.com/claim",
      "value": "12347"
    }
  ],
  "status": "active",
  "type": {
    "coding": [
      {
        "system": "http://hl7.org/fhir/ex-claimtype",
        "code": "oral"
      }
    ]
  },
  "use": "complete",
  "patient": {
    "reference": "#patient-1"
  },
  "created": "2014-08-16",
  "insurer": {
    "reference": "#org-insurer"
  },
  "organization": {
    "reference": "#org-org"
  },
  "priority": {
    "coding": [
      {
        "code": "normal"
      }
    ]
  },
  "payee": {
    "type": {
      "coding": [
        {
          "code": "provider"
        }
      ]
    }
  },
  "careTeam": [
    {
      "sequence": 1,
      "provider": {
        "reference": "#provider-1"
      }
    }
  ],
  "diagnosis": [
    {
      "sequence": 1,
      "diagnosisCodeableConcept": {
        "coding": [
          {
            "code": "123456"
          }
        ]
      }
    }
  ],
  "insurance": [
    {
      "sequence": 1,
      "focal": true,
      "coverage": {
        "reference": "#coverage-1"
      }
    }
  ],
  "item": [
    {
      "sequence": 1,
      "careTeamLinkId": [
        1
      ],
      "service": {
        "coding": [
          {
            "code": "1200"
          }
        ]
      },
      "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"
      }
    }
  ]
}