This page is part of the FHIR Specification (v5.0.0-draft-final: Final QA Preview for R5 - 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)
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:id [ fhir:v "UR3503"] ; #
fhir:text [
fhir:status [ fhir:v "generated" ] ;
fhir: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:identifier ( [
fhir:system [ fhir:v "http://www.SocialBenefitsInc.com/fhir/ClaimResponse"^^xsd:anyURI ] ;
fhir:value [ fhir:v "UR3503" ]
] ) ; #
fhir:status [ fhir:v "active"] ; #
fhir:type [
fhir:coding ( [
fhir:system [ fhir:v "http://terminology.hl7.org/CodeSystem/claim-type"^^xsd:anyURI ] ;
fhir:code [ fhir:v "oral" ]
] )
] ; #
fhir:use [ fhir:v "preauthorization"] ; #
fhir:patient [
fhir:reference [ fhir:v "Patient/1" ]
] ; # this is unsolicited therefore no reference to the preauthorization request exists
fhir:created [ fhir:v "2014-08-16"^^xsd:date] ; #
fhir:insurer [
fhir:identifier [
fhir:system [ fhir:v "http://www.jurisdiction.org/insurers"^^xsd:anyURI ] ;
fhir:value [ fhir:v "444123" ]
] # Social Benefits Inc.
] ; #
fhir:requestor [
fhir:reference [ fhir:v "Organization/1" ]
] ; #
fhir:outcome [ fhir:v "complete"] ; #
fhir:disposition [ fhir:v "The enclosed services are authorized for your provision within 30 days of this notice."] ; #
fhir:preAuthRef [ fhir:v "18SS12345"] ; #
fhir:payeeType [
fhir:coding ( [
fhir:system [ fhir:v "http://terminology.hl7.org/CodeSystem/payeetype"^^xsd:anyURI ] ;
fhir:code [ fhir:v "provider" ]
] ) # advise that assignment of benefit is allowed
] ; #
fhir:addItem ( [
fhir:itemSequence ( [ fhir:v "1"^^xsd:positiveInteger ] ) ; # Exam
fhir:productOrService [
fhir:coding ( [
fhir:system [ fhir:v "http://example.org/fhir/oralservicecodes"^^xsd:anyURI ] ;
fhir:code [ fhir:v "1101" ]
] )
] ;
fhir:modifier ( [
fhir:coding ( [
fhir:system [ fhir:v "http://example.org/fhir/modifiers"^^xsd:anyURI ] ;
fhir:code [ fhir:v "x" ] ;
fhir:display [ fhir:v "None" ]
] )
] ) ;
fhir:net [
fhir:value [ fhir:v "250.00"^^xsd:decimal ] ;
fhir:currency [ fhir:v "USD" ] # net set to same value as the eligible amount. Providers will only be reimbursed to the net\/eligible amount less the co-pay.
] ;
fhir:noteNumber ( [ fhir:v "101"^^xsd:positiveInteger ] ) ;
fhir:adjudication ( [
fhir:category [
fhir:coding ( [
fhir:code [ fhir:v "eligible" ]
] )
] ;
fhir:amount [
fhir:value [ fhir:v "250.00"^^xsd:decimal ] ;
fhir:currency [ fhir:v "USD" ]
]
] [
fhir:category [
fhir:coding ( [
fhir:code [ fhir:v "copay" ]
] )
] ;
fhir:amount [
fhir:value [ fhir:v "10.00"^^xsd:decimal ] ;
fhir:currency [ fhir:v "USD" ]
]
] [
fhir:category [
fhir:coding ( [
fhir:code [ fhir:v "eligpercent" ]
] )
] ;
fhir:quantity [
fhir:value [ fhir:v "100.00"^^xsd:decimal ]
]
] [
fhir:category [
fhir:coding ( [
fhir:code [ fhir:v "benefit" ]
] )
] ;
fhir:amount [
fhir:value [ fhir:v "240.00"^^xsd:decimal ] ;
fhir:currency [ fhir:v "USD" ] # insurer will pay up to this amount.
]
] )
] [
fhir:itemSequence ( [ fhir:v "1"^^xsd:positiveInteger ] ) ; # Xray Panel
fhir:productOrService [
fhir:coding ( [
fhir:system [ fhir:v "http://example.org/fhir/oralservicecodes"^^xsd:anyURI ] ;
fhir:code [ fhir:v "2101" ] ;
fhir:display [ fhir:v "Radiograph, series (12)" ]
] )
] ;
fhir:net [
fhir:value [ fhir:v "800.00"^^xsd:decimal ] ;
fhir:currency [ fhir:v "USD" ]
] ;
fhir:adjudication ( [
fhir:category [
fhir:coding ( [
fhir:code [ fhir:v "eligible" ]
] )
] ;
fhir:amount [
fhir:value [ fhir:v "800.00"^^xsd:decimal ] ;
fhir:currency [ fhir:v "USD" ]
]
] [
fhir:category [
fhir:coding ( [
fhir:code [ fhir:v "eligpercent" ]
] )
] ;
fhir:quantity [
fhir:value [ fhir:v "100.00"^^xsd:decimal ]
]
] [
fhir:category [
fhir:coding ( [
fhir:code [ fhir:v "benefit" ]
] )
] ;
fhir:amount [
fhir:value [ fhir:v "800.00"^^xsd:decimal ] ;
fhir:currency [ fhir:v "USD" ]
]
] )
] ) ; # Authorization details , Authorization to receive an exam and an Xray panel
fhir:total ( [
fhir:category [
fhir:coding ( [
fhir:code [ fhir:v "submitted" ]
] )
] ;
fhir:amount [
fhir:value [ fhir:v "1050.00"^^xsd:decimal ] ;
fhir:currency [ fhir:v "USD" ]
]
] [
fhir:category [
fhir:coding ( [
fhir:code [ fhir:v "benefit" ]
] )
] ;
fhir:amount [
fhir:value [ fhir:v "1040.00"^^xsd:decimal ] ;
fhir:currency [ fhir:v "USD" ]
]
] ) ; #
fhir:processNote ( [
fhir:number [ fhir:v "101"^^xsd:positiveInteger ] ;
fhir:type [
fhir:coding ( [
fhir:system [ fhir:v "http://hl7.org/fhir/note-type"^^xsd:anyURI ] ;
fhir:code [ fhir:v "print" ]
] )
] ;
fhir:text [ fhir:v "Please submit a Pre-Authorization request if a more extensive examination or urgent services are required." ] ;
fhir:language [
fhir:coding ( [
fhir:system [ fhir:v "urn:ietf:bcp:47"^^xsd:anyURI ] ;
fhir:code [ fhir:v "en-CA" ]
] )
]
] ) ; #
fhir:insurance ( [
fhir:sequence [ fhir:v "1"^^xsd:positiveInteger ] ;
fhir:focal [ fhir:v "true"^^xsd:boolean ] ;
fhir:coverage [
fhir:reference [ fhir:v "Coverage/9876B1" ]
]
] )] . #
# -------------------------------------------------------------------------------------
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.
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