This page is part of the electronic Long-Term Services and Supports Implementation Guide (v0.1.0: STU 1 Ballot 1) based on FHIR R4. The current version which supercedes this version is 1.0.0. For a full list of available versions, see the Directory of published versions

eLTSS Claim Example - XML Representation

(back to narrative)

Raw xml

<Bundle xmlns="http://hl7.org/fhir">
  <id value="claim-claim1"/>
  <type value="collection"/>
<!--      The claim for the subject of the document.  -->
  <entry>
    <fullUrl value="http://example.org/eLTSS/claim"/>
    <resource>
      <Claim>
        <id value="claim1"/>
        <meta>
          <profile
                   value="http://hl7.org/fhir/us/eltss/StructureDefinition/claim-eltss"/>
        </meta>
        <text>
          <status value="generated"/>
          <div xmlns="http://www.w3.org/1999/xhtml"><p><b>Generated Narrative with Details</b></p><p><b>id</b>: claim1</p><p><b>meta</b>: </p><p><b>status</b>: active</p><p><b>type</b>: Professional <span style="background: LightGoldenRodYellow">(Details : {http://terminology.hl7.org/CodeSystem/claim-type code 'professional' = 'Professional)</span></p><p><b>use</b>: claim</p><p><b>patient</b>: <a href="Patient/Patient2">Patient/Patient2</a></p><p><b>created</b>: 01/01/2019 12:00:00 AM</p><p><b>provider</b>: <a href="Organization/funding1">Organization/funding1</a></p><p><b>priority</b>: Normal <span style="background: LightGoldenRodYellow">(Details : {http://terminology.hl7.org/CodeSystem/processpriority code 'normal' = 'Normal)</span></p><h3>Insurances</h3><table class="grid"><tr><td>-</td><td><b>Sequence</b></td><td><b>Focal</b></td><td><b>Coverage</b></td></tr><tr><td>*</td><td>1</td><td>true</td><td><a href="Coverage/coverage1">Coverage/coverage1</a></td></tr></table><h3>Items</h3><table class="grid"><tr><td>-</td><td><b>Sequence</b></td><td><b>ProductOrService</b></td><td><b>UnitPrice</b></td><td><b>Net</b></td></tr><tr><td>*</td><td>1</td><td>Exam, comp, primary <span style="background: LightGoldenRodYellow">(Details : {http://terminology.hl7.org/CodeSystem/ex-USCLS code '1101' = 'Exam, comp, primary)</span></td><td/><td/></tr></table></div>
        </text>
        <status value="active"/>
        <type>
          <coding>
            <system value="http://terminology.hl7.org/CodeSystem/claim-type"/>
            <code value="professional"/>
          </coding>
        </type>
        <use value="claim"/>
        <patient>
          <reference value="Patient/Patient2"/>
        </patient>
        <created value="2019-01-01"/>
        <provider>
          <reference value="Organization/funding1"/>
        </provider>
        <priority>
          <coding>
            <system
                    value="http://terminology.hl7.org/CodeSystem/processpriority"/>
            <code value="normal"/>
          </coding>
        </priority>
        <insurance>
          <sequence value="1"/>
          <focal value="true"/>
          <coverage>
            <reference value="Coverage/coverage1"/>
          </coverage>
        </insurance>
        <item>
          <sequence value="1"/>
          <productOrService>
            <coding>
              <system value="http://terminology.hl7.org/CodeSystem/ex-USCLS"/>
              <code value="1101"/>
            </coding>
          </productOrService>
        <!--  eLTSS Service Rate per Unit]   -->
          <unitPrice>
            <value value="60.00"/>
          </unitPrice>
        <!--  eLTSS Total Cost of Service]   -->
          <net>
            <value value="600.00"/>
          </net>
        </item>
      </Claim>
    </resource>
  </entry>
  <entry>
    <fullUrl value="http://example.org/eLTSS/funding"/>
    <resource>
      <Organization>
        <id value="funding1"/>
        <text>
          <status value="generated"/>
          <div xmlns="http://www.w3.org/1999/xhtml">
            <p><b>Service Funding Source:</b> Georgia Department of Community Health</p>
          </div>
        </text>
      <!--  identifier is required by US Core  -->
        <identifier>
          <value value="ICWP"/>
        </identifier>
      <!--  [eLTSS Service Funding Source]  -->
        <name value="Georgia Department of Community Health"/>
      <!--  address is required by US Core  -->
        <address>
          <text value="2 Main Street, Atlanta GA, 30318"/>
        </address>
      </Organization>
    </resource>
  </entry>
  <entry>
    <fullUrl value="http://example.org/eLTSS/coverage1"/>
    <resource>
      <Coverage>
        <id value="coverage1"/>
        <text>
          <status value="generated"/>
          <div xmlns="http://www.w3.org/1999/xhtml"><p><b>Generated Narrative with Details</b></p><p><b>id</b>: coverage1</p><p><b>status</b>: active</p><p><b>beneficiary</b>: <a href="Patient/Patient2">Patient/Patient2</a></p><p><b>payor</b>: <a href="Organization/funding1">Organization/funding1</a></p></div>
        </text>
      <!--  Links to the eLTSS Service Funding Source   -->
        <status value="active"/>
        <beneficiary>
          <reference value="Patient/Patient2"/>
        </beneficiary>
        <payor>
          <reference value="Organization/funding1"/>
        </payor>
      </Coverage>
    </resource>
  </entry>
<!--      The person (Patient) who is the subject of the document.  -->
  <entry>
    <fullUrl value="http://example.org/eLTSS/patient1"/>
    <resource>
      <Patient>
        <id value="Patient2"/>
        <meta>
          <profile
                   value="http://hl7.org/fhir/us/eltss/StructureDefinition/patient-eltss"/>
        </meta>
        <text>
          <status value="generated"/>
          <div xmlns="http://www.w3.org/1999/xhtml">
            <p><b>Person Name:</b> Sally Person</p>
            <p><b>Person Identifier | Type:</b> 123456ABC | MRN</p>
            <p><b>Person Phone:</b> (404) 555 1212</p>
            <p><b>Person Date of Birth:</b> 1935-05-01</p>
            <p><b>Person Address:</b> 2222 Peachtree Street, Atlanta GA, 30318</p>
            <p><b>Emergency Contact Name:</b> Jane Daughter</p>
            <p><b>Emergency Contact Relationship:</b> daughter</p>
            <p><b>Emergency Contact Phone Number:</b> (770) 224 1544</p>
          </div>
        </text>
      <!--  [eLTSS Person Identifier] & [eLTSS Person Identifier Type]   -->
        <identifier>
          <type>
            <coding>
              <system value="http://terminology.hl7.org/CodeSystem/v2-0203"/>
              <code value="MR"/>
            </coding>
          </type>
          <system value="http://www.example.org/Codesystem"/>
          <value value="123456ABC"/>
        </identifier>
      <!--   [eLTSS Person Name]   -->
        <name>
          <text value="Sally Person"/>
          <family value="Person"/>
          <given value="Sally"/>
        </name>
      <!--   [eLTSS Person Phone Number]   -->
        <telecom>
          <system value="phone"/>
          <value value="(404) 555 1212"/>
        </telecom>
        <gender value="female"/>
      <!--   [eLTSS Person Date of Birth]   -->
        <birthDate value="1935-05-01"/>
      <!--   [eLTSS Person Address]   -->
        <address>
          <text value="2222 Peachtree Street, Atlanta GA, 30318"/>
          <line value="2222 Peachtree Street"/>
          <city value="Atlanta"/>
          <district value="Fulton"/>
          <state value="GA"/>
          <postalCode value="30318"/>
        </address>
      <!--   [eLTSS Emergency Contact Name] & [eLTSS Emergency Contact Relationship] & [eLTSS Emergency Contact Phone Number]  -->
        <contact>
          <relationship>
          <!--  code value indicates emergency contact  -->
            <coding>
              <system value="http://terminology.hl7.org/fhir/v2/0131"/>
              <code value="C"/>
            </coding>
          </relationship>
          <relationship>
          <!--  code value indicates daughter  -->
            <coding>
              <system value="http://terminology.hl7.org/fhir/v3/RoleCode"/>
              <code value="DAUC"/>
            </coding>
          </relationship>
          <name>
            <text value="Jane Daughter"/>
            <family value="Daughter"/>
            <given value="Jane"/>
          </name>
          <telecom>
            <system value="phone"/>
            <value value="(770) 224 1544"/>
          </telecom>
        </contact>
      </Patient>
    </resource>
  </entry>
</Bundle>