R4 Draft for Comment
This page is part of the FHIR Specification (v3.2.0: R4 Ballot 1). 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
Claim-example-oral-bridge.json

Financial Management Work Group
Maturity Level: N/A
Ballot Status: Informative
Compartments: Encounter, Patient, Practitioner, RelatedPerson
Raw JSON (canonical form)
PreAuthorization with Bridge and Crown
{
  "resourceType": "Claim",
  "id": "100156",
  "text": {
    "status": "generated",
    "div": "<div xmlns=\"http://www.w3.org/1999/xhtml\">A human-readable rendering of the Oral Health Claim</div>"
  },
  "contained": [
    {
      "resourceType": "Device",
      "id": "device-bridge"
    },
    {
      "resourceType": "ServiceRequest",
      "id": "referral",
      "status": "active",
      "intent": "order",
      "subject": {
        "reference": "Patient/1"
      }
    }
  ],
  "identifier": [
    {
      "system": "http://happyvalley.com/claim",
      "value": "123466"
    }
  ],
  "status": "active",
  "type": {
    "coding": [
      {
        "system": "http://hl7.org/fhir/ex-claimtype",
        "code": "oral"
      }
    ]
  },
  "use": "complete",
  "patient": {
    "reference": "Patient/1"
  },
  "created": "2014-08-16",
  "insurer": {
    "reference": "Organization/2"
  },
  "organization": {
    "reference": "Organization/1"
  },
  "priority": {
    "coding": [
      {
        "code": "normal"
      }
    ]
  },
  "related": [
    {
      "claim": {
        "reference": "Claim/100151"
      },
      "relationship": {
        "coding": [
          {
            "system": "http://hl7.org/fhir/ex-relatedclaimrelationship",
            "code": "associated"
          }
        ]
      },
      "reference": {
        "value": "CASE156746B"
      }
    }
  ],
  "payee": {
    "type": {
      "coding": [
        {
          "system": "http://hl7.org/fhir/payeetype",
          "code": "other"
        }
      ]
    },
    "resource": {
      "code": "relatedperson"
    },
    "party": {
      "reference": "RelatedPerson/peter"
    }
  },
  "referral": {
    "reference": "#referral"
  },
  "careTeam": [
    {
      "sequence": 1,
      "provider": {
        "reference": "Practitioner/example"
      }
    }
  ],
  "information": [
    {
      "sequence": 1,
      "category": {
        "coding": [
          {
            "system": "http://hl7.org/fhir/claiminformationcategory",
            "code": "prosthesis"
          }
        ]
      },
      "code": {
        "coding": [
          {
            "system": "http://hl7.org/fhir/ex-oralprostho",
            "code": "2",
            "display": "Maryland Bridge"
          }
        ]
      },
      "timingDate": "2001-04-07"
    }
  ],
  "procedure": [
    {
      "sequence": 1,
      "date": "2014-07-04",
      "procedureCodeableConcept": {
        "text": "Resection of gum to increase exposed tooth."
      }
    }
  ],
  "insurance": [
    {
      "sequence": 1,
      "focal": true,
      "coverage": {
        "reference": "Coverage/9876B1"
      }
    }
  ],
  "item": [
    {
      "sequence": 1,
      "careTeamSequence": [
        1
      ],
      "informationSequence": [
        1
      ],
      "service": {
        "coding": [
          {
            "system": "http://example.org/fhir/oralservicecodes",
            "code": "67221",
            "display": "Maryland Bridge"
          }
        ]
      },
      "servicedDate": "2014-08-16",
      "locationCodeableConcept": {
        "coding": [
          {
            "system": "http://hl7.org/fhir/ex-serviceplace",
            "code": "11"
          }
        ]
      },
      "unitPrice": {
        "value": 1400.00,
        "system": "urn:iso:std:iso:4217",
        "code": "USD"
      },
      "factor": 0.75,
      "net": {
        "value": 1050.00,
        "system": "urn:iso:std:iso:4217",
        "code": "USD"
      },
      "udi": [
        {
          "reference": "#device-bridge"
        }
      ],
      "bodySite": {
        "coding": [
          {
            "system": "http://fdi.org/fhir/oraltoothcodes",
            "code": "01"
          }
        ]
      }
    },
    {
      "sequence": 2,
      "careTeamSequence": [
        1
      ],
      "service": {
        "coding": [
          {
            "system": "http://example.org/fhir/oralservicecodes",
            "code": "21211"
          }
        ]
      },
      "servicedDate": "2014-08-16",
      "locationCodeableConcept": {
        "coding": [
          {
            "system": "http://hl7.org/fhir/ex-serviceplace",
            "code": "11"
          }
        ]
      },
      "unitPrice": {
        "value": 105.00,
        "system": "urn:iso:std:iso:4217",
        "code": "USD"
      },
      "net": {
        "value": 105.00,
        "system": "urn:iso:std:iso:4217",
        "code": "USD"
      },
      "bodySite": {
        "coding": [
          {
            "system": "http://fdi.org/fhir/oraltoothcodes",
            "code": "21"
          }
        ]
      },
      "subSite": [
        {
          "coding": [
            {
              "system": "http://fdi.org/fhir/oralsurfacecodes",
              "code": "L"
            }
          ]
        }
      ]
    },
    {
      "sequence": 3,
      "careTeamSequence": [
        1
      ],
      "procedureSequence": [
        1
      ],
      "service": {
        "coding": [
          {
            "system": "http://example.org/fhir/oralservicecodes",
            "code": "27211"
          }
        ]
      },
      "servicedDate": "2014-08-16",
      "locationCodeableConcept": {
        "coding": [
          {
            "system": "http://hl7.org/fhir/ex-serviceplace",
            "code": "11"
          }
        ]
      },
      "unitPrice": {
        "value": 1100.00,
        "system": "urn:iso:std:iso:4217",
        "code": "USD"
      },
      "net": {
        "value": 1100.00,
        "system": "urn:iso:std:iso:4217",
        "code": "USD"
      },
      "bodySite": {
        "coding": [
          {
            "system": "http://fdi.org/fhir/oraltoothcodes",
            "code": "24"
          }
        ]
      },
      "detail": [
        {
          "sequence": 1,
          "service": {
            "coding": [
              {
                "system": "http://example.org/fhir/oralservicecodes",
                "code": "27211"
              }
            ]
          },
          "unitPrice": {
            "value": 1000.00,
            "system": "urn:iso:std:iso:4217",
            "code": "USD"
          },
          "factor": 0.75,
          "net": {
            "value": 750.00,
            "system": "urn:iso:std:iso:4217",
            "code": "USD"
          }
        },
        {
          "sequence": 2,
          "service": {
            "coding": [
              {
                "system": "http://example.org/fhir/oralservicecodes",
                "code": "lab"
              }
            ]
          },
          "unitPrice": {
            "value": 350.00,
            "system": "urn:iso:std:iso:4217",
            "code": "USD"
          },
          "net": {
            "value": 350.00,
            "system": "urn:iso:std:iso:4217",
            "code": "USD"
          }
        }
      ]
    }
  ],
  "total": {
    "value": 2255.00,
    "system": "urn:iso: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.