Release 5 Ballot

This page is part of the FHIR Specification (v5.0.0-ballot: R5 Ballot - see ballot notes). 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

Example ClaimResponse/UR3503 (Turtle)

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

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

Unsolicited Pre-Authorization for social Dental Services

@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 -------------------------------------------------------------------

[a fhir:ClaimResponse;
  fhir:nodeRole fhir:treeRoot;
  fhir:Resource.id [ fhir:value "UR3503"];
  fhir:DomainResource.text [
     fhir:Narrative.status [ fhir:value "generated" ];
     fhir:Narrative.div "<div xmlns=\"http://www.w3.org/1999/xhtml\">A sample unsolicited pre-authorization response which authorizes basic dental services to be performed for a patient.</div>"
  ];
  fhir:ClaimResponse.identifier [
     fhir:index 0;
     fhir:Identifier.system [ fhir:value "http://www.SocialBenefitsInc.com/fhir/ClaimResponse" ];
     fhir:Identifier.value [ fhir:value "UR3503" ]
  ];
  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 "oral" ]
     ]
  ];
  fhir:ClaimResponse.use [ fhir:value "preauthorization"];
  fhir:ClaimResponse.patient [
     fhir:Reference.reference [ fhir:value "Patient/1" ]
  ];
  fhir:ClaimResponse.created [ fhir:value "2014-08-16"^^xsd:date];
  fhir:ClaimResponse.insurer [
     fhir:Reference.identifier [
       fhir:Identifier.system [ fhir:value "http://www.jurisdiction.org/insurers" ];
       fhir:Identifier.value [ fhir:value "444123" ]
     ]
  ];
  fhir:ClaimResponse.requestor [
     fhir:Reference.reference [ fhir:value "Organization/1" ]
  ];
  fhir:ClaimResponse.outcome [ fhir:value "complete"];
  fhir:ClaimResponse.disposition [ fhir:value "The enclosed services are authorized for your provision within 30 days of this notice."];
  fhir:ClaimResponse.preAuthRef [ fhir:value "18SS12345"];
  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.addItem [
     fhir:index 0;
     fhir:ClaimResponse.addItem.itemSequence [
       fhir:value "1"^^xsd:positiveInteger;
       fhir:index 0
     ];
     fhir:ClaimResponse.addItem.productOrService [
       fhir:CodeableConcept.coding [
         fhir:index 0;
         fhir:Coding.system [ fhir:value "http://example.org/fhir/oralservicecodes" ];
         fhir:Coding.code [ fhir:value "1101" ]
       ]
     ];
     fhir:ClaimResponse.addItem.modifier [
       fhir:index 0;
       fhir:CodeableConcept.coding [
         fhir:index 0;
         fhir:Coding.system [ fhir:value "http://example.org/fhir/modifiers" ];
         fhir:Coding.code [ fhir:value "x" ];
         fhir:Coding.display [ fhir:value "None" ]
       ]
     ];
     fhir:ClaimResponse.addItem.net [
       fhir:Money.value [ fhir:value "250.00"^^xsd:decimal ];
       fhir:Money.currency [ fhir:value "USD" ]
     ];
     fhir:ClaimResponse.addItem.noteNumber [
       fhir:value "101"^^xsd:positiveInteger;
       fhir:index 0
     ];
     fhir:ClaimResponse.addItem.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 "250.00"^^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 "10.00"^^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 "100.00"^^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 "240.00"^^xsd:decimal ];
         fhir:Money.currency [ fhir:value "USD" ]
       ]
     ]
  ], [
     fhir:index 1;
     fhir:ClaimResponse.addItem.itemSequence [
       fhir:value "1"^^xsd:positiveInteger;
       fhir:index 0
     ];
     fhir:ClaimResponse.addItem.productOrService [
       fhir:CodeableConcept.coding [
         fhir:index 0;
         fhir:Coding.system [ fhir:value "http://example.org/fhir/oralservicecodes" ];
         fhir:Coding.code [ fhir:value "2101" ];
         fhir:Coding.display [ fhir:value "Radiograph, series (12)" ]
       ]
     ];
     fhir:ClaimResponse.addItem.net [
       fhir:Money.value [ fhir:value "800.00"^^xsd:decimal ];
       fhir:Money.currency [ fhir:value "USD" ]
     ];
     fhir:ClaimResponse.addItem.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 "800.00"^^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 "100.00"^^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 "800.00"^^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 "1050.00"^^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 "1040.00"^^xsd:decimal ];
       fhir:Money.currency [ fhir:value "USD" ]
     ]
  ];
  fhir:ClaimResponse.processNote [
     fhir:index 0;
     fhir:ClaimResponse.processNote.number [ fhir:value "101"^^xsd:positiveInteger ];
     fhir:ClaimResponse.processNote.type [ fhir:value "print" ];
     fhir:ClaimResponse.processNote.text [ fhir:value "Please submit a Pre-Authorization request if a more extensive examination or urgent services are required." ];
     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" ]
       ]
     ]
  ];
  fhir:ClaimResponse.insurance [
     fhir:index 0;
     fhir:ClaimResponse.insurance.sequence [ fhir:value "1"^^xsd:positiveInteger ];
     fhir:ClaimResponse.insurance.focal [ fhir:value "true"^^xsd:boolean ];
     fhir:ClaimResponse.insurance.coverage [
       fhir:Reference.reference [ fhir:value "Coverage/9876B1" ]
     ]
  ]] .

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

[a owl:Ontology;
  owl:imports fhir:fhir.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.