Electronic Long-Term Services and Supports (eLTSS) Release 1 - US Realm
2.0.0-ballot - ballot United States of America flag

This page is part of the electronic Long-Term Services and Supports Implementation Guide (v2.0.0-ballot: STU2 Ballot 1) based on FHIR (HL7® FHIR® Standard) R4. The current version which supersedes this version is 1.0.0. For a full list of available versions, see the Directory of published versions

Example Claim: claim2

Page standards status: Informative

Generated Narrative: Claim

Resource Claim "claim2" Version "1" Updated "2020-09-03 10:16:03-0400"

Information Source: #KZ0jzPjXDrhCiMif!

Profile: Claim_eltss

status: active

type: Professional (Claim Type Codes#professional)

use: claim

patient: Patient/patientBSJ1 " SMITH-JOHNSON"

created: 2020-05-01

provider: Organization/funding1 "Texas Department of Community Health"

priority: Normal (Process Priority Codes#normal)

Insurances

-SequenceFocalCoverage
*1trueCoverage/coverage1

item

sequence: 1

productOrService: G0108 (HCFA Procedure Codes (HCPCS)#G0108)

UnitPrices

-Value
*55

Nets

-Value
*660