R4 Ballot #1 (Mixed Normative/Trial use)
This page is part of the FHIR Specification (v3.3.0: R4 Ballot 2). 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
| Financial Management Work Group | Maturity Level: N/A | Ballot Status: Informative | Compartments: Encounter, Patient, Practitioner, RelatedPerson |
Glasses Claim, 3 Tier, Secondary Coverage
Financial
{
"resourceType": "Claim",
"id": "660152",
"text": {
"status": "generated",
"div": "<div xmlns=\"http://www.w3.org/1999/xhtml\">A human-readable rendering of the Vision Claim for Glasses</div>"
},
"contained": [
{
"resourceType": "ClaimResponse",
"id": "claimresponse-1",
"identifier": [
{
"system": "http://thebenefircompany.com/claimresponse",
"value": "CR6532875367"
}
]
},
{
"resourceType": "Device",
"id": "device-frame"
},
{
"resourceType": "Device",
"id": "device-lens"
}
],
"identifier": [
{
"system": "http://happysight.com/claim",
"value": "6612347"
}
],
"status": "active",
"type": {
"coding": [
{
"system": "http://hl7.org/fhir/claim-type",
"code": "vision"
}
]
},
"use": "complete",
"patient": {
"reference": "Patient/1"
},
"created": "2014-08-16",
"insurer": {
"reference": "Organization/2"
},
"provider": {
"reference": "Organization/1"
},
"priority": {
"coding": [
{
"code": "normal"
}
]
},
"prescription": {
"reference": "http://www.optdocs.com/prescription/12345"
},
"payee": {
"type": {
"coding": [
{
"code": "provider"
}
]
}
},
"careTeam": [
{
"sequence": 1,
"provider": {
"reference": "Practitioner/example"
}
}
],
"diagnosis": [
{
"sequence": 1,
"diagnosisCodeableConcept": {
"coding": [
{
"code": "654321"
}
]
}
}
],
"insurance": [
{
"sequence": 1,
"focal": false,
"coverage": {
"reference": "Coverage/9876B1"
},
"preAuthRef": [
"PR7652387237"
],
"claimResponse": {
"reference": "#claimresponse-1"
}
},
{
"sequence": 2,
"focal": true,
"coverage": {
"reference": "Coverage/9876B1"
},
"preAuthRef": [
"AB543GTD7567"
]
}
],
"item": [
{
"sequence": 1,
"careTeamSequence": [
1
],
"revenue": {
"coding": [
{
"system": "http://hl7.org/fhir/ex-revenue-center",
"code": "0010",
"display": "Vision Clinic"
}
]
},
"category": {
"coding": [
{
"system": "http://hl7.org/fhir/benefit-subcategory",
"code": "F6",
"display": "Vision Coverage"
}
]
},
"service": {
"coding": [
{
"system": "http://hl7.org/fhir/ex-visionservice",
"code": "glasses"
}
]
},
"modifier": [
{
"coding": [
{
"system": "http://hl7.org/fhir/modifiers",
"code": "rooh"
}
]
}
],
"programCode": [
{
"coding": [
{
"system": "http://hl7.org/fhir/ex-programcode",
"code": "none"
}
]
}
],
"servicedDate": "2014-08-16",
"unitPrice": {
"value": 235.40,
"system": "urn:iso:std:iso:4217",
"code": "USD"
},
"net": {
"value": 235.40,
"system": "urn:iso:std:iso:4217",
"code": "USD"
},
"detail": [
{
"sequence": 1,
"revenue": {
"coding": [
{
"system": "http://hl7.org/fhir/ex-revenue-center",
"code": "0010",
"display": "Vision Clinic"
}
]
},
"category": {
"coding": [
{
"system": "http://hl7.org/fhir/benefit-subcategory",
"code": "F6",
"display": "Vision Coverage"
}
]
},
"service": {
"coding": [
{
"system": "http://hl7.org/fhir/ex-visionservice",
"code": "frame"
}
]
},
"modifier": [
{
"coding": [
{
"system": "http://hl7.org/fhir/modifiers",
"code": "rooh"
}
]
}
],
"unitPrice": {
"value": 100.00,
"system": "urn:iso:std:iso:4217",
"code": "USD"
},
"factor": 1.1,
"net": {
"value": 110.00,
"system": "urn:iso:std:iso:4217",
"code": "USD"
},
"udi": [
{
"reference": "#device-frame"
}
]
},
{
"sequence": 2,
"revenue": {
"coding": [
{
"system": "http://hl7.org/fhir/ex-revenue-center",
"code": "0010",
"display": "Vision Clinic"
}
]
},
"category": {
"coding": [
{
"system": "http://hl7.org/fhir/benefit-subcategory",
"code": "F6",
"display": "Vision Coverage"
}
]
},
"service": {
"coding": [
{
"system": "http://hl7.org/fhir/ex-visionservice",
"code": "lens"
}
]
},
"programCode": [
{
"coding": [
{
"system": "http://hl7.org/fhir/ex-programcode",
"code": "none"
}
]
}
],
"quantity": {
"value": 2
},
"unitPrice": {
"value": 55.00,
"system": "urn:iso:std:iso:4217",
"code": "USD"
},
"net": {
"value": 110.00,
"system": "urn:iso:std:iso:4217",
"code": "USD"
},
"subDetail": [
{
"sequence": 1,
"revenue": {
"coding": [
{
"system": "http://hl7.org/fhir/ex-revenue-center",
"code": "0010",
"display": "Vision Clinic"
}
]
},
"category": {
"coding": [
{
"system": "http://hl7.org/fhir/benefit-subcategory",
"code": "F6",
"display": "Vision Coverage"
}
]
},
"service": {
"coding": [
{
"system": "http://hl7.org/fhir/ex-visionservice",
"code": "lens"
}
]
},
"modifier": [
{
"coding": [
{
"system": "http://hl7.org/fhir/modifiers",
"code": "rooh"
}
]
}
],
"programCode": [
{
"coding": [
{
"system": "http://hl7.org/fhir/ex-programcode",
"code": "none"
}
]
}
],
"quantity": {
"value": 2
},
"unitPrice": {
"value": 30.00,
"system": "urn:iso:std:iso:4217",
"code": "USD"
},
"factor": 1.1,
"net": {
"value": 66.00,
"system": "urn:iso:std:iso:4217",
"code": "USD"
},
"udi": [
{
"reference": "#device-lens"
}
]
},
{
"sequence": 2,
"revenue": {
"coding": [
{
"system": "http://hl7.org/fhir/ex-revenue-center",
"code": "0010",
"display": "Vision Clinic"
}
]
},
"category": {
"coding": [
{
"system": "http://hl7.org/fhir/benefit-subcategory",
"code": "F6",
"display": "Vision Coverage"
}
]
},
"service": {
"coding": [
{
"system": "http://hl7.org/fhir/ex-visionservice",
"code": "hardening"
}
]
},
"modifier": [
{
"coding": [
{
"system": "http://hl7.org/fhir/modifiers",
"code": "rooh"
}
]
}
],
"quantity": {
"value": 2
},
"unitPrice": {
"value": 15.00,
"system": "urn:iso:std:iso:4217",
"code": "USD"
},
"factor": 1.1,
"net": {
"value": 33.00,
"system": "urn:iso:std:iso:4217",
"code": "USD"
}
},
{
"sequence": 3,
"revenue": {
"coding": [
{
"system": "http://hl7.org/fhir/ex-revenue-center",
"code": "0010",
"display": "Vision Clinic"
}
]
},
"category": {
"coding": [
{
"system": "http://hl7.org/fhir/benefit-subcategory",
"code": "F6",
"display": "Vision Coverage"
}
]
},
"service": {
"coding": [
{
"system": "http://hl7.org/fhir/ex-visionservice",
"code": "UV coating"
}
]
},
"modifier": [
{
"coding": [
{
"system": "http://hl7.org/fhir/modifiers",
"code": "rooh"
}
]
}
],
"quantity": {
"value": 2
},
"unitPrice": {
"value": 5.00,
"system": "urn:iso:std:iso:4217",
"code": "USD"
},
"factor": 1.1,
"net": {
"value": 11.00,
"system": "urn:iso:std:iso:4217",
"code": "USD"
}
}
]
},
{
"sequence": 3,
"revenue": {
"coding": [
{
"system": "http://hl7.org/fhir/ex-revenue-center",
"code": "0010",
"display": "Vision Clinic"
}
]
},
"category": {
"coding": [
{
"system": "http://hl7.org/fhir/benefit-subcategory",
"code": "F6",
"display": "Vision Coverage"
}
]
},
"service": {
"coding": [
{
"system": "http://hl7.org/fhir/ex-visionservice",
"code": "fst"
}
]
},
"unitPrice": {
"value": 220.00,
"system": "urn:iso:std:iso:4217",
"code": "USD"
},
"factor": 0.07,
"net": {
"value": 15.40,
"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 Mixed Nomative/Trial Use Ballot (v3.3.0-13671) generated on Tue, Apr 3, 2018 12:14+1000. QA Page
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