R4 Ballot #2 (Mixed Normative/Trial use)

This page is part of the FHIR Specification (v3.5.0: 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

Claim-example-vision-glasses-3tier.ttl

Financial Management Work GroupMaturity Level: N/ABallot Status: InformativeCompartments: Encounter, Patient, Practitioner, RelatedPerson

Raw Turtle (+ also see Turtle/RDF Format Specification)

Glasses Claim, 3 Tier, Secondary Coverage

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

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

<http://hl7.org/fhir/Claim/660152> a fhir:Claim;
  fhir:nodeRole fhir:treeRoot;
  fhir:Resource.id [ fhir:value "660152"];
  fhir:DomainResource.text [
     fhir:Narrative.status [ fhir:value "generated" ];
     fhir:Narrative.div "<div xmlns=\"http://www.w3.org/1999/xhtml\">A human-readable rendering of the Vision Claim for Glasses</div>"
  ];
  fhir:DomainResource.contained [
     a fhir:ClaimResponse;
     fhir:index 0;
     fhir:Resource.id [ fhir:value "claimresponse-1" ];
     fhir:ClaimResponse.identifier [
       fhir:index 0;
       fhir:Identifier.system [ fhir:value "http://thebenefircompany.com/claimresponse" ];
       fhir:Identifier.value [ fhir:value "CR6532875367" ]
     ];
     fhir:ClaimResponse.use [ fhir:value "claim" ]
  ], [
     a fhir:Device;
     fhir:index 1;
     fhir:Resource.id [ fhir:value "device-frame" ]
  ], [
     a fhir:Device;
     fhir:index 2;
     fhir:Resource.id [ fhir:value "device-lens" ]
  ];
  fhir:Claim.identifier [
     fhir:index 0;
     fhir:Identifier.system [ fhir:value "http://happysight.com/claim" ];
     fhir:Identifier.value [ fhir:value "6612347" ]
  ];
  fhir:Claim.status [ fhir:value "active"];
  fhir:Claim.type [
     fhir:CodeableConcept.coding [
       fhir:index 0;
       fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/claim-type" ];
       fhir:Coding.code [ fhir:value "vision" ]
     ]
  ];
  fhir:Claim.use [ fhir:value "claim"];
  fhir:Claim.patient [
     fhir:link <http://hl7.org/fhir/Patient/1>;
     fhir:Reference.reference [ fhir:value "Patient/1" ]
  ];
  fhir:Claim.created [ fhir:value "2014-08-16"^^xsd:date];
  fhir:Claim.insurer [
     fhir:link <http://hl7.org/fhir/Organization/2>;
     fhir:Reference.reference [ fhir:value "Organization/2" ]
  ];
  fhir:Claim.provider [
     fhir:link <http://hl7.org/fhir/Organization/1>;
     fhir:Reference.reference [ fhir:value "Organization/1" ]
  ];
  fhir:Claim.priority [
     fhir:CodeableConcept.coding [
       fhir:index 0;
       fhir:Coding.code [ fhir:value "normal" ]
     ]
  ];
  fhir:Claim.prescription [
     fhir:link <http://www.optdocs.com/prescription/12345>;
     fhir:Reference.reference [ fhir:value "http://www.optdocs.com/prescription/12345" ]
  ];
  fhir:Claim.payee [
     fhir:Claim.payee.type [
       fhir:CodeableConcept.coding [
         fhir:index 0;
         fhir:Coding.code [ fhir:value "provider" ]
       ]
     ]
  ];
  fhir:Claim.careTeam [
     fhir:index 0;
     fhir:Claim.careTeam.sequence [ fhir:value "1"^^xsd:positiveInteger ];
     fhir:Claim.careTeam.provider [
       fhir:link <http://hl7.org/fhir/Practitioner/example>;
       fhir:Reference.reference [ fhir:value "Practitioner/example" ]
     ]
  ];
  fhir:Claim.diagnosis [
     fhir:index 0;
     fhir:Claim.diagnosis.sequence [ fhir:value "1"^^xsd:positiveInteger ];
     fhir:Claim.diagnosis.diagnosisCodeableConcept [
       fhir:CodeableConcept.coding [
         fhir:index 0;
         fhir:Coding.code [ fhir:value "654321" ]
       ]
     ]
  ];
  fhir:Claim.insurance [
     fhir:index 0;
     fhir:Claim.insurance.sequence [ fhir:value "1"^^xsd:positiveInteger ];
     fhir:Claim.insurance.focal [ fhir:value "false"^^xsd:boolean ];
     fhir:Claim.insurance.coverage [
       fhir:link <http://hl7.org/fhir/Coverage/9876B1>;
       fhir:Reference.reference [ fhir:value "Coverage/9876B1" ]
     ];
     fhir:Claim.insurance.preAuthRef [
       fhir:value "PR7652387237";
       fhir:index 0
     ];
     fhir:Claim.insurance.claimResponse [
       fhir:Reference.reference [ fhir:value "#claimresponse-1" ]
     ]
  ], [
     fhir:index 1;
     fhir:Claim.insurance.sequence [ fhir:value "2"^^xsd:positiveInteger ];
     fhir:Claim.insurance.focal [ fhir:value "true"^^xsd:boolean ];
     fhir:Claim.insurance.coverage [
       fhir:link <http://hl7.org/fhir/Coverage/9876B1>;
       fhir:Reference.reference [ fhir:value "Coverage/9876B1" ]
     ];
     fhir:Claim.insurance.preAuthRef [
       fhir:value "AB543GTD7567";
       fhir:index 0
     ]
  ];
  fhir:Claim.item [
     fhir:index 0;
     fhir:Claim.item.sequence [ fhir:value "1"^^xsd:positiveInteger ];
     fhir:Claim.item.careTeamSequence [
       fhir:value "1"^^xsd:positiveInteger;
       fhir:index 0
     ];
     fhir:Claim.item.revenue [
       fhir:CodeableConcept.coding [
         fhir:index 0;
         fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/ex-revenue-center" ];
         fhir:Coding.code [ fhir:value "0010" ];
         fhir:Coding.display [ fhir:value "Vision Clinic" ]
       ]
     ];
     fhir:Claim.item.category [
       fhir:CodeableConcept.coding [
         fhir:index 0;
         fhir:Coding.system [ fhir:value "http://example.org/fhir/CodeSystem/benefit-subcategory" ];
         fhir:Coding.code [ fhir:value "F6" ];
         fhir:Coding.display [ fhir:value "Vision Coverage" ]
       ]
     ];
     fhir:Claim.item.billcode [
       fhir:CodeableConcept.coding [
         fhir:index 0;
         fhir:Coding.system [ fhir:value "http://example.org/fhir/CodeSystem/ex-visionservice" ];
         fhir:Coding.code [ fhir:value "glasses" ]
       ]
     ];
     fhir:Claim.item.modifier [
       fhir:index 0;
       fhir:CodeableConcept.coding [
         fhir:index 0;
         fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/modifiers" ];
         fhir:Coding.code [ fhir:value "rooh" ]
       ]
     ];
     fhir:Claim.item.programCode [
       fhir:index 0;
       fhir:CodeableConcept.coding [
         fhir:index 0;
         fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/ex-programcode" ];
         fhir:Coding.code [ fhir:value "none" ]
       ]
     ];
     fhir:Claim.item.servicedDate [ fhir:value "2014-08-16"^^xsd:date ];
     fhir:Claim.item.unitPrice [
       fhir:Money.value [ fhir:value "235.40"^^xsd:decimal ];
       fhir:Money.currency [ fhir:value "USD" ]
     ];
     fhir:Claim.item.net [
       fhir:Money.value [ fhir:value "235.40"^^xsd:decimal ];
       fhir:Money.currency [ fhir:value "USD" ]
     ];
     fhir:Claim.item.detail [
       fhir:index 0;
       fhir:Claim.item.detail.sequence [ fhir:value "1"^^xsd:positiveInteger ];
       fhir:Claim.item.detail.revenue [
         fhir:CodeableConcept.coding [
           fhir:index 0;
           fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/ex-revenue-center" ];
           fhir:Coding.code [ fhir:value "0010" ];
           fhir:Coding.display [ fhir:value "Vision Clinic" ]
         ]
       ];
       fhir:Claim.item.detail.category [
         fhir:CodeableConcept.coding [
           fhir:index 0;
           fhir:Coding.system [ fhir:value "http://example.org/fhir/CodeSystem/benefit-subcategory" ];
           fhir:Coding.code [ fhir:value "F6" ];
           fhir:Coding.display [ fhir:value "Vision Coverage" ]
         ]
       ];
       fhir:Claim.item.detail.billcode [
         fhir:CodeableConcept.coding [
           fhir:index 0;
           fhir:Coding.system [ fhir:value "http://example.org/fhir/CodeSystem/ex-visionservice" ];
           fhir:Coding.code [ fhir:value "frame" ]
         ]
       ];
       fhir:Claim.item.detail.modifier [
         fhir:index 0;
         fhir:CodeableConcept.coding [
           fhir:index 0;
           fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/modifiers" ];
           fhir:Coding.code [ fhir:value "rooh" ]
         ]
       ];
       fhir:Claim.item.detail.unitPrice [
         fhir:Money.value [ fhir:value "100.00"^^xsd:decimal ];
         fhir:Money.currency [ fhir:value "USD" ]
       ];
       fhir:Claim.item.detail.factor [ fhir:value "1.1"^^xsd:decimal ];
       fhir:Claim.item.detail.net [
         fhir:Money.value [ fhir:value "110.00"^^xsd:decimal ];
         fhir:Money.currency [ fhir:value "USD" ]
       ];
       fhir:Claim.item.detail.udi [
         fhir:index 0;
         fhir:Reference.reference [ fhir:value "#device-frame" ]
       ]
     ], [
       fhir:index 1;
       fhir:Claim.item.detail.sequence [ fhir:value "2"^^xsd:positiveInteger ];
       fhir:Claim.item.detail.revenue [
         fhir:CodeableConcept.coding [
           fhir:index 0;
           fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/ex-revenue-center" ];
           fhir:Coding.code [ fhir:value "0010" ];
           fhir:Coding.display [ fhir:value "Vision Clinic" ]
         ]
       ];
       fhir:Claim.item.detail.category [
         fhir:CodeableConcept.coding [
           fhir:index 0;
           fhir:Coding.system [ fhir:value "http://example.org/fhir/CodeSystem/benefit-subcategory" ];
           fhir:Coding.code [ fhir:value "F6" ];
           fhir:Coding.display [ fhir:value "Vision Coverage" ]
         ]
       ];
       fhir:Claim.item.detail.billcode [
         fhir:CodeableConcept.coding [
           fhir:index 0;
           fhir:Coding.system [ fhir:value "http://example.org/fhir/CodeSystem/ex-visionservice" ];
           fhir:Coding.code [ fhir:value "lens" ]
         ]
       ];
       fhir:Claim.item.detail.programCode [
         fhir:index 0;
         fhir:CodeableConcept.coding [
           fhir:index 0;
           fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/ex-programcode" ];
           fhir:Coding.code [ fhir:value "none" ]
         ]
       ];
       fhir:Claim.item.detail.quantity [
         fhir:Quantity.value [ fhir:value "2"^^xsd:decimal ]
       ];
       fhir:Claim.item.detail.unitPrice [
         fhir:Money.value [ fhir:value "55.00"^^xsd:decimal ];
         fhir:Money.currency [ fhir:value "USD" ]
       ];
       fhir:Claim.item.detail.net [
         fhir:Money.value [ fhir:value "110.00"^^xsd:decimal ];
         fhir:Money.currency [ fhir:value "USD" ]
       ];
       fhir:Claim.item.detail.subDetail [
         fhir:index 0;
         fhir:Claim.item.detail.subDetail.sequence [ fhir:value "1"^^xsd:positiveInteger ];
         fhir:Claim.item.detail.subDetail.revenue [
           fhir:CodeableConcept.coding [
             fhir:index 0;
             fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/ex-revenue-center" ];
             fhir:Coding.code [ fhir:value "0010" ];
             fhir:Coding.display [ fhir:value "Vision Clinic" ]
           ]
         ];
         fhir:Claim.item.detail.subDetail.category [
           fhir:CodeableConcept.coding [
             fhir:index 0;
             fhir:Coding.system [ fhir:value "http://example.org/fhir/CodeSystem/benefit-subcategory" ];
             fhir:Coding.code [ fhir:value "F6" ];
             fhir:Coding.display [ fhir:value "Vision Coverage" ]
           ]
         ];
         fhir:Claim.item.detail.subDetail.billcode [
           fhir:CodeableConcept.coding [
             fhir:index 0;
             fhir:Coding.system [ fhir:value "http://example.org/fhir/CodeSystem/ex-visionservice" ];
             fhir:Coding.code [ fhir:value "lens" ]
           ]
         ];
         fhir:Claim.item.detail.subDetail.modifier [
           fhir:index 0;
           fhir:CodeableConcept.coding [
             fhir:index 0;
             fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/modifiers" ];
             fhir:Coding.code [ fhir:value "rooh" ]
           ]
         ];
         fhir:Claim.item.detail.subDetail.programCode [
           fhir:index 0;
           fhir:CodeableConcept.coding [
             fhir:index 0;
             fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/ex-programcode" ];
             fhir:Coding.code [ fhir:value "none" ]
           ]
         ];
         fhir:Claim.item.detail.subDetail.quantity [
           fhir:Quantity.value [ fhir:value "2"^^xsd:decimal ]
         ];
         fhir:Claim.item.detail.subDetail.unitPrice [
           fhir:Money.value [ fhir:value "30.00"^^xsd:decimal ];
           fhir:Money.currency [ fhir:value "USD" ]
         ];
         fhir:Claim.item.detail.subDetail.factor [ fhir:value "1.1"^^xsd:decimal ];
         fhir:Claim.item.detail.subDetail.net [
           fhir:Money.value [ fhir:value "66.00"^^xsd:decimal ];
           fhir:Money.currency [ fhir:value "USD" ]
         ];
         fhir:Claim.item.detail.subDetail.udi [
           fhir:index 0;
           fhir:Reference.reference [ fhir:value "#device-lens" ]
         ]
       ], [
         fhir:index 1;
         fhir:Claim.item.detail.subDetail.sequence [ fhir:value "2"^^xsd:positiveInteger ];
         fhir:Claim.item.detail.subDetail.revenue [
           fhir:CodeableConcept.coding [
             fhir:index 0;
             fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/ex-revenue-center" ];
             fhir:Coding.code [ fhir:value "0010" ];
             fhir:Coding.display [ fhir:value "Vision Clinic" ]
           ]
         ];
         fhir:Claim.item.detail.subDetail.category [
           fhir:CodeableConcept.coding [
             fhir:index 0;
             fhir:Coding.system [ fhir:value "http://example.org/fhir/CodeSystem/benefit-subcategory" ];
             fhir:Coding.code [ fhir:value "F6" ];
             fhir:Coding.display [ fhir:value "Vision Coverage" ]
           ]
         ];
         fhir:Claim.item.detail.subDetail.billcode [
           fhir:CodeableConcept.coding [
             fhir:index 0;
             fhir:Coding.system [ fhir:value "http://example.org/fhir/CodeSystem/ex-visionservice" ];
             fhir:Coding.code [ fhir:value "hardening" ]
           ]
         ];
         fhir:Claim.item.detail.subDetail.modifier [
           fhir:index 0;
           fhir:CodeableConcept.coding [
             fhir:index 0;
             fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/modifiers" ];
             fhir:Coding.code [ fhir:value "rooh" ]
           ]
         ];
         fhir:Claim.item.detail.subDetail.quantity [
           fhir:Quantity.value [ fhir:value "2"^^xsd:decimal ]
         ];
         fhir:Claim.item.detail.subDetail.unitPrice [
           fhir:Money.value [ fhir:value "15.00"^^xsd:decimal ];
           fhir:Money.currency [ fhir:value "USD" ]
         ];
         fhir:Claim.item.detail.subDetail.factor [ fhir:value "1.1"^^xsd:decimal ];
         fhir:Claim.item.detail.subDetail.net [
           fhir:Money.value [ fhir:value "33.00"^^xsd:decimal ];
           fhir:Money.currency [ fhir:value "USD" ]
         ]
       ], [
         fhir:index 2;
         fhir:Claim.item.detail.subDetail.sequence [ fhir:value "3"^^xsd:positiveInteger ];
         fhir:Claim.item.detail.subDetail.revenue [
           fhir:CodeableConcept.coding [
             fhir:index 0;
             fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/ex-revenue-center" ];
             fhir:Coding.code [ fhir:value "0010" ];
             fhir:Coding.display [ fhir:value "Vision Clinic" ]
           ]
         ];
         fhir:Claim.item.detail.subDetail.category [
           fhir:CodeableConcept.coding [
             fhir:index 0;
             fhir:Coding.system [ fhir:value "http://example.org/fhir/CodeSystem/benefit-subcategory" ];
             fhir:Coding.code [ fhir:value "F6" ];
             fhir:Coding.display [ fhir:value "Vision Coverage" ]
           ]
         ];
         fhir:Claim.item.detail.subDetail.billcode [
           fhir:CodeableConcept.coding [
             fhir:index 0;
             fhir:Coding.system [ fhir:value "http://example.org/fhir/CodeSystem/ex-visionservice" ];
             fhir:Coding.code [ fhir:value "UV coating" ]
           ]
         ];
         fhir:Claim.item.detail.subDetail.modifier [
           fhir:index 0;
           fhir:CodeableConcept.coding [
             fhir:index 0;
             fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/modifiers" ];
             fhir:Coding.code [ fhir:value "rooh" ]
           ]
         ];
         fhir:Claim.item.detail.subDetail.quantity [
           fhir:Quantity.value [ fhir:value "2"^^xsd:decimal ]
         ];
         fhir:Claim.item.detail.subDetail.unitPrice [
           fhir:Money.value [ fhir:value "5.00"^^xsd:decimal ];
           fhir:Money.currency [ fhir:value "USD" ]
         ];
         fhir:Claim.item.detail.subDetail.factor [ fhir:value "1.1"^^xsd:decimal ];
         fhir:Claim.item.detail.subDetail.net [
           fhir:Money.value [ fhir:value "11.00"^^xsd:decimal ];
           fhir:Money.currency [ fhir:value "USD" ]
         ]
       ]
     ], [
       fhir:index 2;
       fhir:Claim.item.detail.sequence [ fhir:value "3"^^xsd:positiveInteger ];
       fhir:Claim.item.detail.revenue [
         fhir:CodeableConcept.coding [
           fhir:index 0;
           fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/ex-revenue-center" ];
           fhir:Coding.code [ fhir:value "0010" ];
           fhir:Coding.display [ fhir:value "Vision Clinic" ]
         ]
       ];
       fhir:Claim.item.detail.category [
         fhir:CodeableConcept.coding [
           fhir:index 0;
           fhir:Coding.system [ fhir:value "http://example.org/fhir/CodeSystem/benefit-subcategory" ];
           fhir:Coding.code [ fhir:value "F6" ];
           fhir:Coding.display [ fhir:value "Vision Coverage" ]
         ]
       ];
       fhir:Claim.item.detail.billcode [
         fhir:CodeableConcept.coding [
           fhir:index 0;
           fhir:Coding.system [ fhir:value "http://example.org/fhir/CodeSystem/ex-visionservice" ];
           fhir:Coding.code [ fhir:value "fst" ]
         ]
       ];
       fhir:Claim.item.detail.unitPrice [
         fhir:Money.value [ fhir:value "220.00"^^xsd:decimal ];
         fhir:Money.currency [ fhir:value "USD" ]
       ];
       fhir:Claim.item.detail.factor [ fhir:value "0.07"^^xsd:decimal ];
       fhir:Claim.item.detail.net [
         fhir:Money.value [ fhir:value "15.40"^^xsd:decimal ];
         fhir:Money.currency [ fhir:value "USD" ]
       ]
     ]
  ] .

<http://hl7.org/fhir/Patient/1> a fhir:Patient .

<http://hl7.org/fhir/Organization/2> a fhir:Organization .

<http://hl7.org/fhir/Organization/1> a fhir:Organization .

<http://hl7.org/fhir/Practitioner/example> a fhir:Practitioner .

<http://hl7.org/fhir/Coverage/9876B1> a fhir:Coverage .

# - ontology header ------------------------------------------------------------

<http://hl7.org/fhir/Claim/660152.ttl> a owl:Ontology;
  owl:imports fhir:fhir.ttl;
  owl:versionIRI <http://build.fhir.org/Claim/660152.ttl> .

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

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.