DSTU2 Ballot Source

This page is part of the FHIR Specification (v0.5.0: DSTU 2 Ballot 2). 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 R3 R2

Claim-example-oral-orthoplan.json

Raw JSON (canonical form)

PreAuthorization with Orthodontic Treatment Plan

{
  "resourceType": "Claim",
  "id": "100153",
  "text": {
    "status": "generated",
    "div": "<div>!-- Snipped for Brevity --></div>"
  },
  "type": "oral",
  "identifier": [
    {
      "system": "http://happyvalley.com/claim",
      "value": "12355"
    }
  ],
  "created": "2015-03-16",
  "target": {
    "reference": "Organization/2"
  },
  "organization": {
    "reference": "Organization/1"
  },
  "use": "proposed",
  "priority": {
    "code": "normal"
  },
  "payee": {
    "type": {
      "code": "provider"
    }
  },
  "diagnosis": [
    {
      "sequence": 1,
      "diagnosis": {
        "system": "http://hl7.org/fhir/icd-10",
        "code": "123457"
      }
    }
  ],
  "patient": {
    "reference": "Patient/1"
  },
  "coverage": [
    {
      "sequence": 1,
      "focal": true,
      "coverage": {
        "reference": "Coverage/9876B1"
      },
      "relationship": {
        "code": "self"
      }
    }
  ],
  "item": [
    {
      "sequence": 1,
      "type": {
        "system": "http://hl7.org/fhir/actinvoicegroupcode",
        "code": "group"
      },
      "provider": {
        "reference": "Practitioner/1"
      },
      "diagnosisLinkId": [
        1
      ],
      "service": {
        "system": "http://hl7.org/fhir/oralservicecodes",
        "code": "ORTHPLAN"
      },
      "serviceDate": "2015-05-16",
      "unitPrice": {
        "value": 9000.00,
        "system": "urn:std:iso:4217",
        "code": "USD"
      },
      "net": {
        "value": 9000.00,
        "system": "urn:std:iso:4217",
        "code": "USD"
      },
      "detail": [
        {
          "sequence": 1,
          "type": {
            "system": "http://hl7.org/fhir/actinvoicegroupcode",
            "code": "service"
          },
          "service": {
            "system": "http://hl7.org/fhir/oralservicecodes",
            "code": "ORTHOEXAM"
          },
          "unitPrice": {
            "value": 1000.00,
            "system": "urn:std:iso:4217",
            "code": "USD"
          },
          "net": {
            "value": 1000.00,
            "system": "urn:std:iso:4217",
            "code": "USD"
          }
        },
        {
          "sequence": 2,
          "type": {
            "system": "http://hl7.org/fhir/actinvoicegroupcode",
            "code": "service"
          },
          "service": {
            "system": "http://hl7.org/fhir/oralservicecodes",
            "code": "ORTHODIAG"
          },
          "unitPrice": {
            "value": 1500.00,
            "system": "urn:std:iso:4217",
            "code": "USD"
          },
          "net": {
            "value": 1500.00,
            "system": "urn:std:iso:4217",
            "code": "USD"
          }
        },
        {
          "sequence": 3,
          "type": {
            "system": "http://hl7.org/fhir/actinvoicegroupcode",
            "code": "service"
          },
          "service": {
            "system": "http://hl7.org/fhir/oralservicecodes",
            "code": "ORTHOINITIAL"
          },
          "unitPrice": {
            "value": 500.00,
            "system": "urn:std:iso:4217",
            "code": "USD"
          },
          "net": {
            "value": 500.00,
            "system": "urn:std:iso:4217",
            "code": "USD"
          }
        },
        {
          "sequence": 4,
          "type": {
            "system": "http://hl7.org/fhir/actinvoicegroupcode",
            "code": "service"
          },
          "service": {
            "system": "http://hl7.org/fhir/oralservicecodes",
            "code": "ORTHOMONTHS"
          },
          "quantity": {
            "value": 24
          }
        },
        {
          "sequence": 5,
          "type": {
            "system": "http://hl7.org/fhir/actinvoicegroupcode",
            "code": "service"
          },
          "service": {
            "system": "http://hl7.org/fhir/oralservicecodes",
            "code": "ORTHOPERIODIC"
          },
          "quantity": {
            "value": 24
          },
          "unitPrice": {
            "value": 250.00,
            "system": "urn:std:iso:4217",
            "code": "USD"
          },
          "net": {
            "value": 250.00,
            "system": "urn:std:iso:4217",
            "code": "USD"
          }
        }
      ]
    },
    {
      "sequence": 2,
      "type": {
        "code": "service"
      },
      "provider": {
        "reference": "Practitioner/1"
      },
      "service": {
        "system": "http://hl7.org/fhir/oralservicecodes",
        "code": "21211"
      },
      "serviceDate": "2014-08-16",
      "unitPrice": {
        "value": 105.00,
        "system": "urn:std:iso:4217",
        "code": "USD"
      },
      "net": {
        "value": 105.00,
        "system": "urn:std:iso:4217",
        "code": "USD"
      },
      "bodySite": {
        "system": "http://fdi.org/fhir/oraltoothcodes",
        "code": "21"
      },
      "subSite": [
        {
          "system": "http://fdi.org/fhir/oralsurfacecodes",
          "code": "L"
        }
      ]
    },
    {
      "sequence": 3,
      "type": {
        "code": "group"
      },
      "provider": {
        "reference": "Practitioner/1"
      },
      "service": {
        "system": "http://hl7.org/fhir/oralservicecodes",
        "code": "27211"
      },
      "serviceDate": "2014-08-16",
      "unitPrice": {
        "value": 1100.00,
        "system": "urn:std:iso:4217",
        "code": "USD"
      },
      "net": {
        "value": 1100.00,
        "system": "urn:std:iso:4217",
        "code": "USD"
      },
      "bodySite": {
        "system": "http://fdi.org/fhir/oraltoothcodes",
        "code": "36"
      },
      "detail": [
        {
          "sequence": 1,
          "type": {
            "code": "service"
          },
          "service": {
            "system": "http://hl7.org/fhir/oralservicecodes",
            "code": "27211"
          },
          "unitPrice": {
            "value": 750.00,
            "system": "urn:std:iso:4217",
            "code": "USD"
          },
          "net": {
            "value": 750.00,
            "system": "urn:std:iso:4217",
            "code": "USD"
          }
        },
        {
          "sequence": 2,
          "type": {
            "code": "service"
          },
          "service": {
            "system": "http://hl7.org/fhir/oralservicecodes",
            "code": "lab"
          },
          "unitPrice": {
            "value": 350.00,
            "system": "urn:std:iso:4217",
            "code": "USD"
          },
          "net": {
            "value": 350.00,
            "system": "urn:std:iso:4217",
            "code": "USD"
          }
        }
      ]
    }
  ]
}

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.