This page is part of the FHIR Specification (v5.0.0-ballot: FHIR R5 Ballot Preview). 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 | Standards Status: Informative | Compartments: Device, Encounter, Patient, Practitioner, RelatedPerson |
Raw JSON (canonical form + also see JSON Format Specification)
PreAuthorization with Bridge and Crown
{ "resourceType": "Claim", "id": "100156", "text": { "status": "generated", "div": "<div xmlns=\"http://www.w3.org/1999/xhtml\">A human-readable rendering of the Oral Health Claim</div>" }, "contained": [ { "resourceType": "Device", "id": "device-bridge" }, { "resourceType": "ServiceRequest", "id": "referral", "status": "active", "intent": "order", "subject": { "reference": "Patient/1" } } ], "identifier": [ { "system": "http://happyvalley.com/claim", "value": "123466" } ], "status": "active", "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claim-type", "code": "oral" } ] }, "use": "claim", "patient": { "reference": "Patient/1" }, "created": "2014-08-16", "insurer": { "reference": "Organization/2" }, "provider": { "reference": "Organization/1" }, "priority": { "coding": [ { "code": "normal" } ] }, "related": [ { "claim": { "reference": "Claim/100151" }, "relationship": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/ex-relatedclaimrelationship", "code": "associated" } ] }, "reference": { "value": "CASE156746B" } } ], "payee": { "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/payeetype", "code": "other" } ] }, "party": { "reference": "RelatedPerson/peter" } }, "referral": { "reference": "#referral" }, "careTeam": [ { "sequence": 1, "provider": { "reference": "Practitioner/example" } } ], "supportingInfo": [ { "sequence": 1, "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claiminformationcategory", "code": "prosthesis" } ] }, "code": { "coding": [ { "system": "http://hl7.org/fhir/ex-oralprostho", "code": "2", "display": "Maryland Bridge" } ] }, "timingDate": "2001-04-07" } ], "procedure": [ { "sequence": 1, "date": "2014-07-04", "procedureCodeableConcept": { "text": "Resection of gum to increase exposed tooth." } } ], "insurance": [ { "sequence": 1, "focal": true, "coverage": { "reference": "Coverage/9876B1" } } ], "item": [ { "sequence": 1, "careTeamSequence": [ 1 ], "informationSequence": [ 1 ], "productOrService": { "coding": [ { "system": "http://example.org/fhir/oralservicecodes", "code": "67221", "display": "Maryland Bridge" } ] }, "servicedDate": "2014-08-16", "locationCodeableConcept": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace", "code": "11" } ] }, "unitPrice": { "value": 1400.00, "currency": "USD" }, "factor": 0.75, "net": { "value": 1050.00, "currency": "USD" }, "udi": [ { "reference": "#device-bridge" } ], "bodySite": [ { "site": [ { "concept": { "coding": [ { "system": "http://fdi.org/fhir/oraltoothcodes", "code": "01" } ] } } ] } ] }, { "sequence": 2, "careTeamSequence": [ 1 ], "productOrService": { "coding": [ { "system": "http://example.org/fhir/oralservicecodes", "code": "21211" } ] }, "servicedDate": "2014-08-16", "locationCodeableConcept": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace", "code": "11" } ] }, "unitPrice": { "value": 105.00, "currency": "USD" }, "net": { "value": 105.00, "currency": "USD" }, "bodySite": [ { "site": [ { "concept": { "coding": [ { "system": "http://fdi.org/fhir/oraltoothcodes", "code": "21" } ] } } ], "subSite": [ { "coding": [ { "system": "http://fdi.org/fhir/oralsurfacecodes", "code": "L" } ] } ] } ] }, { "sequence": 3, "careTeamSequence": [ 1 ], "procedureSequence": [ 1 ], "productOrService": { "coding": [ { "system": "http://example.org/fhir/oralservicecodes", "code": "27211" } ] }, "servicedDate": "2014-08-16", "locationCodeableConcept": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace", "code": "11" } ] }, "unitPrice": { "value": 1100.00, "currency": "USD" }, "net": { "value": 1100.00, "currency": "USD" }, "bodySite": [ { "site": [ { "concept": { "coding": [ { "system": "http://fdi.org/fhir/oraltoothcodes", "code": "24" } ] } } ] } ], "detail": [ { "sequence": 1, "productOrService": { "coding": [ { "system": "http://example.org/fhir/oralservicecodes", "code": "27211" } ] }, "unitPrice": { "value": 1000.00, "currency": "USD" }, "factor": 0.75, "net": { "value": 750.00, "currency": "USD" } }, { "sequence": 2, "productOrService": { "coding": [ { "system": "http://example.org/fhir/oralservicecodes", "code": "lab" } ] }, "unitPrice": { "value": 350.00, "currency": "USD" }, "net": { "value": 350.00, "currency": "USD" } } ] } ], "total": { "value": 2255.00, "currency": "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.