Release 5 Draft Ballot

This page is part of the FHIR Specification (v4.6.0: R5 Draft Ballot). 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

Claimresponse-example-vision-3tier.ttl

Financial Management Work GroupMaturity Level: N/AStandards Status: InformativeCompartments: Patient, Practitioner

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

Primary insurance response to a 3Tier Vision Claim

@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/ClaimResponse/R3502> a fhir:ClaimResponse;
  fhir:nodeRole fhir:treeRoot;
  fhir:Resource.id [ fhir:value "R3502"];
  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 ClaimResponse</div>"
  ];
  fhir:ClaimResponse.identifier [
     fhir:index 0;
     fhir:Identifier.system [ fhir:value "http://thebenefitcompany.com/claimresponse" ];
     fhir:Identifier.value [ fhir:value "CR6532875367" ]
  ];
  fhir:ClaimResponse.status [ fhir:value "active"];
  fhir:ClaimResponse.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:ClaimResponse.use [ fhir:value "claim"];
  fhir:ClaimResponse.patient [
     fhir:link <http://hl7.org/fhir/Patient/1>;
     fhir:Reference.reference [ fhir:value "Patient/1" ]
  ];
  fhir:ClaimResponse.created [ fhir:value "2014-08-16"^^xsd:date];
  fhir:ClaimResponse.insurer [
     fhir:link <http://hl7.org/fhir/Organization/2>;
     fhir:Reference.reference [ fhir:value "Organization/2" ]
  ];
  fhir:ClaimResponse.requestor [
     fhir:link <http://hl7.org/fhir/Organization/1>;
     fhir:Reference.reference [ fhir:value "Organization/1" ]
  ];
  fhir:ClaimResponse.request [
     fhir:Reference.identifier [
       fhir:Identifier.system [ fhir:value "http://happysight.com/claim" ];
       fhir:Identifier.value [ fhir:value "6612346" ]
     ]
  ];
  fhir:ClaimResponse.outcome [ fhir:value "complete"];
  fhir:ClaimResponse.disposition [ fhir:value "Claim settled as per contract."];
  fhir:ClaimResponse.payeeType [
     fhir:CodeableConcept.coding [
       fhir:index 0;
       fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/payeetype" ];
       fhir:Coding.code [ fhir:value "provider" ]
     ]
  ];
  fhir:ClaimResponse.item [
     fhir:index 0;
     fhir:ClaimResponse.item.itemSequence [ fhir:value "1"^^xsd:positiveInteger ];
     fhir:ClaimResponse.item.adjudication [
       fhir:index 0;
       fhir:ClaimResponse.item.adjudication.category [
         fhir:CodeableConcept.coding [
           fhir:index 0;
           fhir:Coding.code [ fhir:value "eligible" ]
         ]
       ];
       fhir:ClaimResponse.item.adjudication.amount [
         fhir:Money.value [ fhir:value "235.40"^^xsd:decimal ];
         fhir:Money.currency [ fhir:value "USD" ]
       ]
     ], [
       fhir:index 1;
       fhir:ClaimResponse.item.adjudication.category [
         fhir:CodeableConcept.coding [
           fhir:index 0;
           fhir:Coding.code [ fhir:value "copay" ]
         ]
       ];
       fhir:ClaimResponse.item.adjudication.amount [
         fhir:Money.value [ fhir:value "20.00"^^xsd:decimal ];
         fhir:Money.currency [ fhir:value "USD" ]
       ]
     ], [
       fhir:index 2;
       fhir:ClaimResponse.item.adjudication.category [
         fhir:CodeableConcept.coding [
           fhir:index 0;
           fhir:Coding.code [ fhir:value "eligpercent" ]
         ]
       ];
       fhir:ClaimResponse.item.adjudication.value [ fhir:value "80.00"^^xsd:decimal ]
     ], [
       fhir:index 3;
       fhir:ClaimResponse.item.adjudication.category [
         fhir:CodeableConcept.coding [
           fhir:index 0;
           fhir:Coding.code [ fhir:value "benefit" ]
         ]
       ];
       fhir:ClaimResponse.item.adjudication.amount [
         fhir:Money.value [ fhir:value "172.32"^^xsd:decimal ];
         fhir:Money.currency [ fhir:value "USD" ]
       ]
     ];
     fhir:ClaimResponse.item.detail [
       fhir:index 0;
       fhir:ClaimResponse.item.detail.detailSequence [ fhir:value "1"^^xsd:positiveInteger ];
       fhir:ClaimResponse.item.detail.noteNumber [
         fhir:value "1"^^xsd:positiveInteger;
         fhir:index 0
       ];
       fhir:ClaimResponse.item.detail.adjudication [
         fhir:index 0;
         fhir:ClaimResponse.item.adjudication.category [
           fhir:CodeableConcept.coding [
             fhir:index 0;
             fhir:Coding.code [ fhir:value "eligible" ]
           ]
         ];
         fhir:ClaimResponse.item.adjudication.amount [
           fhir:Money.value [ fhir:value "100.00"^^xsd:decimal ];
           fhir:Money.currency [ fhir:value "USD" ]
         ]
       ], [
         fhir:index 1;
         fhir:ClaimResponse.item.adjudication.category [
           fhir:CodeableConcept.coding [
             fhir:index 0;
             fhir:Coding.code [ fhir:value "copay" ]
           ]
         ];
         fhir:ClaimResponse.item.adjudication.amount [
           fhir:Money.value [ fhir:value "20.00"^^xsd:decimal ];
           fhir:Money.currency [ fhir:value "USD" ]
         ]
       ], [
         fhir:index 2;
         fhir:ClaimResponse.item.adjudication.category [
           fhir:CodeableConcept.coding [
             fhir:index 0;
             fhir:Coding.code [ fhir:value "eligpercent" ]
           ]
         ];
         fhir:ClaimResponse.item.adjudication.value [ fhir:value "80.00"^^xsd:decimal ]
       ], [
         fhir:index 3;
         fhir:ClaimResponse.item.adjudication.category [
           fhir:CodeableConcept.coding [
             fhir:index 0;
             fhir:Coding.code [ fhir:value "benefit" ]
           ]
         ];
         fhir:ClaimResponse.item.adjudication.amount [
           fhir:Money.value [ fhir:value "80.00"^^xsd:decimal ];
           fhir:Money.currency [ fhir:value "USD" ]
         ]
       ]
     ], [
       fhir:index 1;
       fhir:ClaimResponse.item.detail.detailSequence [ fhir:value "2"^^xsd:positiveInteger ];
       fhir:ClaimResponse.item.detail.noteNumber [
         fhir:value "1"^^xsd:positiveInteger;
         fhir:index 0
       ];
       fhir:ClaimResponse.item.detail.adjudication [
         fhir:index 0;
         fhir:ClaimResponse.item.adjudication.category [
           fhir:CodeableConcept.coding [
             fhir:index 0;
             fhir:Coding.code [ fhir:value "eligible" ]
           ]
         ];
         fhir:ClaimResponse.item.adjudication.amount [
           fhir:Money.value [ fhir:value "110.00"^^xsd:decimal ];
           fhir:Money.currency [ fhir:value "USD" ]
         ]
       ], [
         fhir:index 1;
         fhir:ClaimResponse.item.adjudication.category [
           fhir:CodeableConcept.coding [
             fhir:index 0;
             fhir:Coding.code [ fhir:value "eligpercent" ]
           ]
         ];
         fhir:ClaimResponse.item.adjudication.value [ fhir:value "80.00"^^xsd:decimal ]
       ], [
         fhir:index 2;
         fhir:ClaimResponse.item.adjudication.category [
           fhir:CodeableConcept.coding [
             fhir:index 0;
             fhir:Coding.code [ fhir:value "benefit" ]
           ]
         ];
         fhir:ClaimResponse.item.adjudication.amount [
           fhir:Money.value [ fhir:value "88.00"^^xsd:decimal ];
           fhir:Money.currency [ fhir:value "USD" ]
         ]
       ];
       fhir:ClaimResponse.item.detail.subDetail [
         fhir:index 0;
         fhir:ClaimResponse.item.detail.subDetail.subDetailSequence [ fhir:value "1"^^xsd:positiveInteger ];
         fhir:ClaimResponse.item.detail.subDetail.noteNumber [
           fhir:value "1"^^xsd:positiveInteger;
           fhir:index 0
         ];
         fhir:ClaimResponse.item.detail.subDetail.adjudication [
           fhir:index 0;
           fhir:ClaimResponse.item.adjudication.category [
             fhir:CodeableConcept.coding [
               fhir:index 0;
               fhir:Coding.code [ fhir:value "eligible" ]
             ]
           ];
           fhir:ClaimResponse.item.adjudication.amount [
             fhir:Money.value [ fhir:value "60.00"^^xsd:decimal ];
             fhir:Money.currency [ fhir:value "USD" ]
           ]
         ], [
           fhir:index 1;
           fhir:ClaimResponse.item.adjudication.category [
             fhir:CodeableConcept.coding [
               fhir:index 0;
               fhir:Coding.code [ fhir:value "eligpercent" ]
             ]
           ];
           fhir:ClaimResponse.item.adjudication.value [ fhir:value "80.00"^^xsd:decimal ]
         ], [
           fhir:index 2;
           fhir:ClaimResponse.item.adjudication.category [
             fhir:CodeableConcept.coding [
               fhir:index 0;
               fhir:Coding.code [ fhir:value "benefit" ]
             ]
           ];
           fhir:ClaimResponse.item.adjudication.amount [
             fhir:Money.value [ fhir:value "48.00"^^xsd:decimal ];
             fhir:Money.currency [ fhir:value "USD" ]
           ]
         ]
       ], [
         fhir:index 1;
         fhir:ClaimResponse.item.detail.subDetail.subDetailSequence [ fhir:value "2"^^xsd:positiveInteger ];
         fhir:ClaimResponse.item.detail.subDetail.adjudication [
           fhir:index 0;
           fhir:ClaimResponse.item.adjudication.category [
             fhir:CodeableConcept.coding [
               fhir:index 0;
               fhir:Coding.code [ fhir:value "eligible" ]
             ]
           ];
           fhir:ClaimResponse.item.adjudication.amount [
             fhir:Money.value [ fhir:value "30.00"^^xsd:decimal ];
             fhir:Money.currency [ fhir:value "USD" ]
           ]
         ], [
           fhir:index 1;
           fhir:ClaimResponse.item.adjudication.category [
             fhir:CodeableConcept.coding [
               fhir:index 0;
               fhir:Coding.code [ fhir:value "eligpercent" ]
             ]
           ];
           fhir:ClaimResponse.item.adjudication.value [ fhir:value "80.00"^^xsd:decimal ]
         ], [
           fhir:index 2;
           fhir:ClaimResponse.item.adjudication.category [
             fhir:CodeableConcept.coding [
               fhir:index 0;
               fhir:Coding.code [ fhir:value "benefit" ]
             ]
           ];
           fhir:ClaimResponse.item.adjudication.amount [
             fhir:Money.value [ fhir:value "24.00"^^xsd:decimal ];
             fhir:Money.currency [ fhir:value "USD" ]
           ]
         ]
       ], [
         fhir:index 2;
         fhir:ClaimResponse.item.detail.subDetail.subDetailSequence [ fhir:value "3"^^xsd:positiveInteger ];
         fhir:ClaimResponse.item.detail.subDetail.noteNumber [
           fhir:value "1"^^xsd:positiveInteger;
           fhir:index 0
         ];
         fhir:ClaimResponse.item.detail.subDetail.adjudication [
           fhir:index 0;
           fhir:ClaimResponse.item.adjudication.category [
             fhir:CodeableConcept.coding [
               fhir:index 0;
               fhir:Coding.code [ fhir:value "eligible" ]
             ]
           ];
           fhir:ClaimResponse.item.adjudication.amount [
             fhir:Money.value [ fhir:value "10.00"^^xsd:decimal ];
             fhir:Money.currency [ fhir:value "USD" ]
           ]
         ], [
           fhir:index 1;
           fhir:ClaimResponse.item.adjudication.category [
             fhir:CodeableConcept.coding [
               fhir:index 0;
               fhir:Coding.code [ fhir:value "eligpercent" ]
             ]
           ];
           fhir:ClaimResponse.item.adjudication.value [ fhir:value "80.00"^^xsd:decimal ]
         ], [
           fhir:index 2;
           fhir:ClaimResponse.item.adjudication.category [
             fhir:CodeableConcept.coding [
               fhir:index 0;
               fhir:Coding.code [ fhir:value "benefit" ]
             ]
           ];
           fhir:ClaimResponse.item.adjudication.amount [
             fhir:Money.value [ fhir:value "8.00"^^xsd:decimal ];
             fhir:Money.currency [ fhir:value "USD" ]
           ]
         ]
       ]
     ], [
       fhir:index 2;
       fhir:ClaimResponse.item.detail.detailSequence [ fhir:value "3"^^xsd:positiveInteger ];
       fhir:ClaimResponse.item.detail.noteNumber [
         fhir:value "1"^^xsd:positiveInteger;
         fhir:index 0
       ];
       fhir:ClaimResponse.item.detail.adjudication [
         fhir:index 0;
         fhir:ClaimResponse.item.adjudication.category [
           fhir:CodeableConcept.coding [
             fhir:index 0;
             fhir:Coding.code [ fhir:value "eligible" ]
           ]
         ];
         fhir:ClaimResponse.item.adjudication.amount [
           fhir:Money.value [ fhir:value "200.00"^^xsd:decimal ];
           fhir:Money.currency [ fhir:value "USD" ]
         ]
       ], [
         fhir:index 1;
         fhir:ClaimResponse.item.adjudication.category [
           fhir:CodeableConcept.coding [
             fhir:index 0;
             fhir:Coding.code [ fhir:value "eligpercent" ]
           ]
         ];
         fhir:ClaimResponse.item.adjudication.value [ fhir:value "80.00"^^xsd:decimal ]
       ], [
         fhir:index 2;
         fhir:ClaimResponse.item.adjudication.category [
           fhir:CodeableConcept.coding [
             fhir:index 0;
             fhir:Coding.code [ fhir:value "benefit" ]
           ]
         ];
         fhir:ClaimResponse.item.adjudication.amount [
           fhir:Money.value [ fhir:value "14.00"^^xsd:decimal ];
           fhir:Money.currency [ fhir:value "USD" ]
         ]
       ]
     ]
  ];
  fhir:ClaimResponse.total [
     fhir:index 0;
     fhir:ClaimResponse.total.category [
       fhir:CodeableConcept.coding [
         fhir:index 0;
         fhir:Coding.code [ fhir:value "submitted" ]
       ]
     ];
     fhir:ClaimResponse.total.amount [
       fhir:Money.value [ fhir:value "235.40"^^xsd:decimal ];
       fhir:Money.currency [ fhir:value "USD" ]
     ]
  ], [
     fhir:index 1;
     fhir:ClaimResponse.total.category [
       fhir:CodeableConcept.coding [
         fhir:index 0;
         fhir:Coding.code [ fhir:value "benefit" ]
       ]
     ];
     fhir:ClaimResponse.total.amount [
       fhir:Money.value [ fhir:value "182.00"^^xsd:decimal ];
       fhir:Money.currency [ fhir:value "USD" ]
     ]
  ];
  fhir:ClaimResponse.payment [
     fhir:ClaimResponse.payment.type [
       fhir:CodeableConcept.coding [
         fhir:index 0;
         fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/ex-paymenttype" ];
         fhir:Coding.code [ fhir:value "complete" ]
       ]
     ];
     fhir:ClaimResponse.payment.adjustment [
       fhir:Money.value [ fhir:value "75.00"^^xsd:decimal ];
       fhir:Money.currency [ fhir:value "USD" ]
     ];
     fhir:ClaimResponse.payment.adjustmentReason [
       fhir:CodeableConcept.coding [
         fhir:index 0;
         fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/payment-adjustment-reason" ];
         fhir:Coding.code [ fhir:value "a002" ];
         fhir:Coding.display [ fhir:value "Prior Overpayment" ]
       ]
     ];
     fhir:ClaimResponse.payment.date [ fhir:value "2014-08-16"^^xsd:date ];
     fhir:ClaimResponse.payment.amount [
       fhir:Money.value [ fhir:value "107.00"^^xsd:decimal ];
       fhir:Money.currency [ fhir:value "USD" ]
     ];
     fhir:ClaimResponse.payment.identifier [
       fhir:Identifier.system [ fhir:value "http://thebenefitcompany.com/paymentidentifier" ];
       fhir:Identifier.value [ fhir:value "201416-123456" ]
     ]
  ];
  fhir:ClaimResponse.processNote [
     fhir:index 0;
     fhir:ClaimResponse.processNote.number [ fhir:value "1"^^xsd:positiveInteger ];
     fhir:ClaimResponse.processNote.type [ fhir:value "display" ];
     fhir:ClaimResponse.processNote.text [ fhir:value "After hours surcharge declined" ];
     fhir:ClaimResponse.processNote.language [
       fhir:CodeableConcept.coding [
         fhir:index 0;
         fhir:Coding.system [ fhir:value "urn:ietf:bcp:47" ];
         fhir:Coding.code [ fhir:value "en-CA" ]
       ]
     ]
  ] .

<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 .

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

<http://hl7.org/fhir/ClaimResponse/R3502.ttl> a owl:Ontology;
  owl:imports fhir:fhir.ttl;
  owl:versionIRI <http://build.fhir.org/ClaimResponse/R3502.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.