Release 5
FinancialThis page is part of the FHIR Specification (v5.0.0: R5 - STU). This is the current published version. For a full list of available versions, see the Directory of published versions 
. Page versions: R5 R4B R4
| Financial Management Work Group | Maturity Level: N/A | Standards Status: Informative | Compartments: 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 -------------------------------------------------------------------
[a fhir:ClaimResponse ;
fhir:nodeRole fhir:treeRoot ;
fhir:id [ fhir:v "R3502"] ; #
fhir:text [
fhir:status [ fhir:v "generated" ] ;
fhir:div "<div xmlns=\"http://www.w3.org/1999/xhtml\">A human-readable rendering of the ClaimResponse</div>"
] ; #
fhir:identifier ( [
fhir:system [ fhir:v "http://thebenefitcompany.com/claimresponse"^^xsd:anyURI ] ;
fhir:value [ fhir:v "CR6532875367" ]
] ) ; #
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 "vision" ]
] )
] ; #
fhir:use [ fhir:v "claim"] ; #
fhir:patient [
fhir:reference [ fhir:v "Patient/1" ]
] ; #
fhir:created [ fhir:v "2014-08-16"^^xsd:date] ; #
fhir:insurer [
fhir:reference [ fhir:v "Organization/2" ]
] ; #
fhir:requestor [
fhir:reference [ fhir:v "Organization/1" ]
] ; #
fhir:request [
fhir:identifier [
fhir:system [ fhir:v "http://happysight.com/claim"^^xsd:anyURI ] ;
fhir:value [ fhir:v "6612346" ]
]
] ; #
fhir:outcome [ fhir:v "complete"] ; #
fhir:disposition [ fhir:v "Claim settled as per contract."] ; #
fhir:payeeType [
fhir:coding ( [
fhir:system [ fhir:v "http://terminology.hl7.org/CodeSystem/payeetype"^^xsd:anyURI ] ;
fhir:code [ fhir:v "provider" ]
] )
] ; #
fhir:item ( [
fhir:itemSequence [ fhir:v "1"^^xsd:positiveInteger ] ;
fhir:adjudication ( [
fhir:category [
fhir:coding ( [
fhir:code [ fhir:v "eligible" ]
] )
] ;
fhir:amount [
fhir:value [ fhir:v "235.40"^^xsd:decimal ] ;
fhir:currency [ fhir:v "USD" ]
]
] [
fhir:category [
fhir:coding ( [
fhir:code [ fhir:v "copay" ]
] )
] ;
fhir:amount [
fhir:value [ fhir:v "20.00"^^xsd:decimal ] ;
fhir:currency [ fhir:v "USD" ]
]
] [
fhir:category [
fhir:coding ( [
fhir:code [ fhir:v "eligpercent" ]
] )
] ;
fhir:quantity [
fhir:value [ fhir:v "80.00"^^xsd:decimal ]
]
] [
fhir:category [
fhir:coding ( [
fhir:code [ fhir:v "benefit" ]
] )
] ;
fhir:amount [
fhir:value [ fhir:v "172.32"^^xsd:decimal ] ;
fhir:currency [ fhir:v "USD" ]
]
] ) ;
fhir:detail ( [
fhir:detailSequence [ fhir:v "1"^^xsd:positiveInteger ] ;
fhir:noteNumber ( [ fhir:v "1"^^xsd:positiveInteger ] ) ;
fhir:adjudication ( [
fhir:category [
fhir:coding ( [
fhir:code [ fhir:v "eligible" ]
] )
] ;
fhir:amount [
fhir:value [ fhir:v "100.00"^^xsd:decimal ] ;
fhir:currency [ fhir:v "USD" ]
]
] [
fhir:category [
fhir:coding ( [
fhir:code [ fhir:v "copay" ]
] )
] ;
fhir:amount [
fhir:value [ fhir:v "20.00"^^xsd:decimal ] ;
fhir:currency [ fhir:v "USD" ]
]
] [
fhir:category [
fhir:coding ( [
fhir:code [ fhir:v "eligpercent" ]
] )
] ;
fhir:quantity [
fhir:value [ fhir:v "80.00"^^xsd:decimal ]
]
] [
fhir:category [
fhir:coding ( [
fhir:code [ fhir:v "benefit" ]
] )
] ;
fhir:amount [
fhir:value [ fhir:v "80.00"^^xsd:decimal ] ;
fhir:currency [ fhir:v "USD" ]
]
] )
] [
fhir:detailSequence [ fhir:v "2"^^xsd:positiveInteger ] ;
fhir:noteNumber ( [ fhir:v "1"^^xsd:positiveInteger ] ) ;
fhir:adjudication ( [
fhir:category [
fhir:coding ( [
fhir:code [ fhir:v "eligible" ]
] )
] ;
fhir:amount [
fhir:value [ fhir:v "110.00"^^xsd:decimal ] ;
fhir:currency [ fhir:v "USD" ]
]
] [
fhir:category [
fhir:coding ( [
fhir:code [ fhir:v "eligpercent" ]
] )
] ;
fhir:quantity [
fhir:value [ fhir:v "80.00"^^xsd:decimal ]
]
] [
fhir:category [
fhir:coding ( [
fhir:code [ fhir:v "benefit" ]
] )
] ;
fhir:amount [
fhir:value [ fhir:v "88.00"^^xsd:decimal ] ;
fhir:currency [ fhir:v "USD" ]
]
] ) ;
fhir:subDetail ( [
fhir:subDetailSequence [ fhir:v "1"^^xsd:positiveInteger ] ;
fhir:noteNumber ( [ fhir:v "1"^^xsd:positiveInteger ] ) ;
fhir:adjudication ( [
fhir:category [
fhir:coding ( [
fhir:code [ fhir:v "eligible" ]
] )
] ;
fhir:amount [
fhir:value [ fhir:v "60.00"^^xsd:decimal ] ;
fhir:currency [ fhir:v "USD" ]
]
] [
fhir:category [
fhir:coding ( [
fhir:code [ fhir:v "eligpercent" ]
] )
] ;
fhir:quantity [
fhir:value [ fhir:v "80.00"^^xsd:decimal ]
]
] [
fhir:category [
fhir:coding ( [
fhir:code [ fhir:v "benefit" ]
] )
] ;
fhir:amount [
fhir:value [ fhir:v "48.00"^^xsd:decimal ] ;
fhir:currency [ fhir:v "USD" ]
]
] )
] [
fhir:subDetailSequence [ fhir:v "2"^^xsd:positiveInteger ] ;
fhir:adjudication ( [
fhir:category [
fhir:coding ( [
fhir:code [ fhir:v "eligible" ]
] )
] ;
fhir:amount [
fhir:value [ fhir:v "30.00"^^xsd:decimal ] ;
fhir:currency [ fhir:v "USD" ]
]
] [
fhir:category [
fhir:coding ( [
fhir:code [ fhir:v "eligpercent" ]
] )
] ;
fhir:quantity [
fhir:value [ fhir:v "80.00"^^xsd:decimal ]
]
] [
fhir:category [
fhir:coding ( [
fhir:code [ fhir:v "benefit" ]
] )
] ;
fhir:amount [
fhir:value [ fhir:v "24.00"^^xsd:decimal ] ;
fhir:currency [ fhir:v "USD" ]
]
] )
] [
fhir:subDetailSequence [ fhir:v "3"^^xsd:positiveInteger ] ;
fhir:noteNumber ( [ fhir:v "1"^^xsd:positiveInteger ] ) ;
fhir:adjudication ( [
fhir:category [
fhir:coding ( [
fhir:code [ fhir:v "eligible" ]
] )
] ;
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 "80.00"^^xsd:decimal ]
]
] [
fhir:category [
fhir:coding ( [
fhir:code [ fhir:v "benefit" ]
] )
] ;
fhir:amount [
fhir:value [ fhir:v "8.00"^^xsd:decimal ] ;
fhir:currency [ fhir:v "USD" ]
]
] )
] )
] [
fhir:detailSequence [ fhir:v "3"^^xsd:positiveInteger ] ;
fhir:noteNumber ( [ fhir:v "1"^^xsd:positiveInteger ] ) ;
fhir:adjudication ( [
fhir:category [
fhir:coding ( [
fhir:code [ fhir:v "eligible" ]
] )
] ;
fhir:amount [
fhir:value [ fhir:v "200.00"^^xsd:decimal ] ;
fhir:currency [ fhir:v "USD" ]
]
] [
fhir:category [
fhir:coding ( [
fhir:code [ fhir:v "eligpercent" ]
] )
] ;
fhir:quantity [
fhir:value [ fhir:v "80.00"^^xsd:decimal ]
]
] [
fhir:category [
fhir:coding ( [
fhir:code [ fhir:v "benefit" ]
] )
] ;
fhir:amount [
fhir:value [ fhir:v "14.00"^^xsd:decimal ] ;
fhir:currency [ fhir:v "USD" ]
]
] )
] )
] ) ; # Adjudication details
fhir:total ( [
fhir:category [
fhir:coding ( [
fhir:code [ fhir:v "submitted" ]
] )
] ;
fhir:amount [
fhir:value [ fhir:v "235.40"^^xsd:decimal ] ;
fhir:currency [ fhir:v "USD" ]
]
] [
fhir:category [
fhir:coding ( [
fhir:code [ fhir:v "benefit" ]
] )
] ;
fhir:amount [
fhir:value [ fhir:v "182.00"^^xsd:decimal ] ;
fhir:currency [ fhir:v "USD" ]
]
] ) ; #
fhir:payment [
fhir:type [
fhir:coding ( [
fhir:system [ fhir:v "http://terminology.hl7.org/CodeSystem/ex-paymenttype"^^xsd:anyURI ] ;
fhir:code [ fhir:v "complete" ]
] )
] ;
fhir:adjustment [
fhir:value [ fhir:v "75.00"^^xsd:decimal ] ;
fhir:currency [ fhir:v "USD" ]
] ;
fhir:adjustmentReason [
fhir:coding ( [
fhir:system [ fhir:v "http://terminology.hl7.org/CodeSystem/payment-adjustment-reason"^^xsd:anyURI ] ;
fhir:code [ fhir:v "a002" ] ;
fhir:display [ fhir:v "Prior Overpayment" ]
] )
] ;
fhir:date [ fhir:v "2014-08-16"^^xsd:date ] ;
fhir:amount [
fhir:value [ fhir:v "107.00"^^xsd:decimal ] ;
fhir:currency [ fhir:v "USD" ]
] ;
fhir:identifier [
fhir:system [ fhir:v "http://thebenefitcompany.com/paymentidentifier"^^xsd:anyURI ] ;
fhir:value [ fhir:v "201416-123456" ]
]
] ; # Payment details
fhir:processNote ( [
fhir:number [ fhir:v "1"^^xsd:positiveInteger ] ;
fhir:type [
fhir:coding ( [
fhir:system [ fhir:v "http://hl7.org/fhir/note-type"^^xsd:anyURI ] ;
fhir:code [ fhir:v "display" ]
] )
] ;
fhir:text [ fhir:v "After hours surcharge declined" ] ;
fhir:language [
fhir:coding ( [
fhir:system [ fhir:v "urn:ietf:bcp:47"^^xsd:anyURI ] ;
fhir:code [ fhir:v "en-CA" ]
] )
]
] )] . #
# -------------------------------------------------------------------------------------
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.
FHIR ®© HL7.org 2011+. FHIR R5 hl7.fhir.core#5.0.0 generated on Sun, Mar 26, 2023 15:24+1100.
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