Electronic Long-Term Services and Supports (eLTSS) Release 1 - US Realm
This page is part of the electronic Long-Term Services and Supports Implementation Guide (v1.0.0: STU 1) based on FHIR (HL7® FHIR® Standard) R4. The current version which supersedes this version is 2.0.0. For a full list of available versions, see the Directory of published versions
{
"resourceType" : "Bundle",
"id" : "claim-claim1",
"type" : "collection",
"entry" : [
{
"fullUrl" : "http://example.org/eLTSS/claim",
"resource" : {
"resourceType" : "Claim",
"id" : "claim1",
"meta" : {
"profile" : [
"http://hl7.org/fhir/us/eltss/StructureDefinition/Claim-eltss"
]
},
"text" : {
"status" : "generated",
"div" : "<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>: Jan 1, 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>"
},
"status" : "active",
"type" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/claim-type",
"code" : "professional"
}
]
},
"use" : "claim",
"patient" : {
"reference" : "Patient/Patient2"
},
"created" : "2019-01-01",
"provider" : {
"reference" : "Organization/funding1"
},
"priority" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/processpriority",
"code" : "normal"
}
]
},
"insurance" : [
{
"sequence" : 1,
"focal" : true,
"coverage" : {
"reference" : "Coverage/coverage1"
}
}
],
"item" : [
{
"sequence" : 1,
"productOrService" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/ex-USCLS",
"code" : "1101"
}
]
},
"unitPrice" : {
"value" : 60.00
},
"net" : {
"value" : 600.00
}
}
]
}
},
{
"fullUrl" : "http://example.org/eLTSS/funding",
"resource" : {
"resourceType" : "Organization",
"id" : "funding1",
"text" : {
"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n <p><b>Service Funding Source:</b> Georgia Department of Community Health</p>\n </div>"
},
"identifier" : [
{
"value" : "ICWP"
}
],
"name" : "Georgia Department of Community Health",
"address" : [
{
"text" : "2 Main Street, Atlanta GA, 30318"
}
]
}
},
{
"fullUrl" : "http://example.org/eLTSS/coverage1",
"resource" : {
"resourceType" : "Coverage",
"id" : "coverage1",
"text" : {
"status" : "generated",
"div" : "<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>"
},
"status" : "active",
"beneficiary" : {
"reference" : "Patient/Patient2"
},
"payor" : [
{
"reference" : "Organization/funding1"
}
]
}
},
{
"fullUrl" : "http://example.org/eLTSS/patient1",
"resource" : {
"resourceType" : "Patient",
"id" : "Patient2",
"meta" : {
"profile" : [
"http://hl7.org/fhir/us/eltss/StructureDefinition/Patient-eltss"
]
},
"text" : {
"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n <p><b>Person Name:</b> Sally Person</p>\n <p><b>Person Identifier | Type:</b> 123456ABC | MRN</p>\n <p><b>Person Phone:</b> (404) 555 1212</p>\n <p><b>Person Date of Birth:</b> 1935-05-01</p>\n <p><b>Person Address:</b> 2222 Peachtree Street, Atlanta GA, 30318</p>\n <p><b>Emergency Contact Name:</b> Jane Daughter</p>\n <p><b>Emergency Contact Relationship:</b> daughter</p>\n <p><b>Emergency Contact Phone Number:</b> (770) 224 1544</p>\n </div>"
},
"identifier" : [
{
"type" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/v2-0203",
"code" : "MR"
}
]
},
"system" : "http://www.example.org/Codesystem",
"value" : "123456ABC"
}
],
"name" : [
{
"text" : "Sally Person",
"family" : "Person",
"given" : [
"Sally"
]
}
],
"telecom" : [
{
"system" : "phone",
"value" : "(404) 555 1212"
}
],
"gender" : "female",
"birthDate" : "1935-05-01",
"address" : [
{
"text" : "2222 Peachtree Street, Atlanta GA, 30318",
"line" : [
"2222 Peachtree Street"
],
"city" : "Atlanta",
"district" : "Fulton",
"state" : "GA",
"postalCode" : "30318"
}
],
"contact" : [
{
"relationship" : [
{
"coding" : [
{
"system" : "http://terminology.hl7.org/fhir/v2/0131",
"code" : "C"
}
]
},
{
"coding" : [
{
"system" : "http://terminology.hl7.org/fhir/v3/RoleCode",
"code" : "DAUC"
}
]
}
],
"name" : {
"text" : "Jane Daughter",
"family" : "Daughter",
"given" : [
"Jane"
]
},
"telecom" : [
{
"system" : "phone",
"value" : "(770) 224 1544"
}
]
}
]
}
}
]
}
Implementation Guide © 2017+ HL7 International Community-Based Care and Privacy Work Group hl7.fhir.us.eltss#1.0.0 based on FHIR v4.0.0 generated 2019-09-12.
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