R4 Ballot #1 (Mixed Normative/Trial use)

This page is part of the FHIR Specification (v3.3.0: R4 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

Claimresponse-example-additem.ttl

Financial Management Work GroupMaturity Level: N/ABallot Status: InformativeCompartments: Patient, Practitioner

Raw Turtle,

A ClaimResponse demonstrating Payor service code substitutions

@prefix fhir: <http://hl7.org/fhir/> .
@prefix owl: <http://www.w3.org/2002/07/owl#> .
@prefix rdfs: <http://www.w3.org/2000/01/rdf-schema#> .
@prefix xsd: <http://www.w3.org/2001/XMLSchema#> .

# - resource -------------------------------------------------------------------

<http://hl7.org/fhir/ClaimResponse/R3503> a fhir:ClaimResponse;
  fhir:nodeRole fhir:treeRoot;
  fhir:Resource.id [ fhir:value "R3503"];
  fhir:DomainResource.text [
     fhir:Narrative.status [ fhir:value "generated" ];
     fhir:Narrative.div "<div xmlns=\"http://www.w3.org/1999/xhtml\">A human-readable rendering of the ClaimResponse to Claim Oral Average with additional items</div>"
  ];
  fhir:ClaimResponse.identifier [
     fhir:index 0;
     fhir:Identifier.system [ fhir:value "http://www.BenefitsInc.com/fhir/remittance" ];
     fhir:Identifier.value [ fhir:value "R3503" ]
  ];
  fhir:ClaimResponse.status [ fhir:value "active"];
  fhir:ClaimResponse.type [
     fhir:CodeableConcept.coding [
       fhir:index 0;
       fhir:Coding.system [ fhir:value "http://hl7.org/fhir/claim-type" ];
       fhir:Coding.code [ fhir:value "oral" ]
     ]
  ];
  fhir:ClaimResponse.use [ fhir:value "complete"];
  fhir:ClaimResponse.patient [
     fhir:link <http://hl7.org/fhir/Patient/1>;
     fhir:Reference.reference [ fhir:value "Patient/1" ]
  ];
  fhir:ClaimResponse.created [ fhir:value "2014-08-16"^^xsd:date];
  fhir:ClaimResponse.insurer [
     fhir:Reference.identifier [
       fhir:Identifier.system [ fhir:value "http://www.jurisdiction.org/insurers" ];
       fhir:Identifier.value [ fhir:value "555123" ]
     ]
  ];
  fhir:ClaimResponse.requestProvider [
     fhir:link <http://hl7.org/fhir/Organization/1>;
     fhir:Reference.reference [ fhir:value "Organization/1" ]
  ];
  fhir:ClaimResponse.request [
     fhir:Reference.identifier [
       fhir:Identifier.system [ fhir:value "http://happyvalley.com/claim" ];
       fhir:Identifier.value [ fhir:value "12346" ]
     ]
  ];
  fhir:ClaimResponse.outcome [ fhir:value "complete"];
  fhir:ClaimResponse.disposition [ fhir:value "Claim settled as per contract."];
  fhir:ClaimResponse.payeeType [
     fhir:CodeableConcept.coding [
       fhir:index 0;
       fhir:Coding.system [ fhir:value "http://hl7.org/fhir/payeetype" ];
       fhir:Coding.code [ fhir:value "provider" ]
     ]
  ];
  fhir:ClaimResponse.item [
     fhir:index 0;
     fhir:ClaimResponse.item.itemSequence [ fhir:value "1"^^xsd:positiveInteger ];
     fhir:ClaimResponse.item.adjudication [
       fhir:index 0;
       fhir:ClaimResponse.item.adjudication.category [
         fhir:CodeableConcept.coding [
           fhir:index 0;
           fhir:Coding.code [ fhir:value "eligible" ]
         ]
       ];
       fhir:ClaimResponse.item.adjudication.amount [
         fhir:Quantity.value [ fhir:value "0.00"^^xsd:decimal ];
         fhir:Quantity.system [ fhir:value "urn:iso:std:iso:4217" ];
         fhir:Quantity.code [ fhir:value "USD" ]
       ]
     ], [
       fhir:index 1;
       fhir:ClaimResponse.item.adjudication.category [
         fhir:CodeableConcept.coding [
           fhir:index 0;
           fhir:Coding.code [ fhir:value "benefit" ]
         ]
       ];
       fhir:ClaimResponse.item.adjudication.amount [
         fhir:Quantity.value [ fhir:value "0.00"^^xsd:decimal ];
         fhir:Quantity.system [ fhir:value "urn:iso:std:iso:4217" ];
         fhir:Quantity.code [ fhir:value "USD" ]
       ]
     ]
  ], [
     fhir:index 1;
     fhir:ClaimResponse.item.itemSequence [ fhir:value "2"^^xsd:positiveInteger ];
     fhir:ClaimResponse.item.adjudication [
       fhir:index 0;
       fhir:ClaimResponse.item.adjudication.category [
         fhir:CodeableConcept.coding [
           fhir:index 0;
           fhir:Coding.code [ fhir:value "eligible" ]
         ]
       ];
       fhir:ClaimResponse.item.adjudication.amount [
         fhir:Quantity.value [ fhir:value "105.00"^^xsd:decimal ];
         fhir:Quantity.system [ fhir:value "urn:iso:std:iso:4217" ];
         fhir:Quantity.code [ fhir:value "USD" ]
       ]
     ], [
       fhir:index 1;
       fhir:ClaimResponse.item.adjudication.category [
         fhir:CodeableConcept.coding [
           fhir:index 0;
           fhir:Coding.code [ fhir:value "eligpercent" ]
         ]
       ];
       fhir:ClaimResponse.item.adjudication.value [ fhir:value "80.00"^^xsd:decimal ]
     ], [
       fhir:index 2;
       fhir:ClaimResponse.item.adjudication.category [
         fhir:CodeableConcept.coding [
           fhir:index 0;
           fhir:Coding.code [ fhir:value "benefit" ]
         ]
       ];
       fhir:ClaimResponse.item.adjudication.amount [
         fhir:Quantity.value [ fhir:value "84.00"^^xsd:decimal ];
         fhir:Quantity.system [ fhir:value "urn:iso:std:iso:4217" ];
         fhir:Quantity.code [ fhir:value "USD" ]
       ]
     ]
  ], [
     fhir:index 2;
     fhir:ClaimResponse.item.itemSequence [ fhir:value "3"^^xsd:positiveInteger ];
     fhir:ClaimResponse.item.adjudication [
       fhir:index 0;
       fhir:ClaimResponse.item.adjudication.category [
         fhir:CodeableConcept.coding [
           fhir:index 0;
           fhir:Coding.code [ fhir:value "eligible" ]
         ]
       ];
       fhir:ClaimResponse.item.adjudication.amount [
         fhir:Quantity.value [ fhir:value "750.00"^^xsd:decimal ];
         fhir:Quantity.system [ fhir:value "urn:iso:std:iso:4217" ];
         fhir:Quantity.code [ fhir:value "USD" ]
       ]
     ], [
       fhir:index 1;
       fhir:ClaimResponse.item.adjudication.category [
         fhir:CodeableConcept.coding [
           fhir:index 0;
           fhir:Coding.code [ fhir:value "eligpercent" ]
         ]
       ];
       fhir:ClaimResponse.item.adjudication.value [ fhir:value "80.00"^^xsd:decimal ]
     ], [
       fhir:index 2;
       fhir:ClaimResponse.item.adjudication.category [
         fhir:CodeableConcept.coding [
           fhir:index 0;
           fhir:Coding.code [ fhir:value "benefit" ]
         ]
       ];
       fhir:ClaimResponse.item.adjudication.amount [
         fhir:Quantity.value [ fhir:value "600.00"^^xsd:decimal ];
         fhir:Quantity.system [ fhir:value "urn:iso:std:iso:4217" ];
         fhir:Quantity.code [ fhir:value "USD" ]
       ]
     ];
     fhir:ClaimResponse.item.detail [
       fhir:index 0;
       fhir:ClaimResponse.item.detail.detailSequence [ fhir:value "1"^^xsd:positiveInteger ];
       fhir:ClaimResponse.item.detail.adjudication [
         fhir:index 0;
         fhir:ClaimResponse.item.adjudication.category [
           fhir:CodeableConcept.coding [
             fhir:index 0;
             fhir:Coding.code [ fhir:value "eligible" ]
           ]
         ];
         fhir:ClaimResponse.item.adjudication.amount [
           fhir:Quantity.value [ fhir:value "750.00"^^xsd:decimal ];
           fhir:Quantity.system [ fhir:value "urn:iso:std:iso:4217" ];
           fhir:Quantity.code [ fhir:value "USD" ]
         ]
       ], [
         fhir:index 1;
         fhir:ClaimResponse.item.adjudication.category [
           fhir:CodeableConcept.coding [
             fhir:index 0;
             fhir:Coding.code [ fhir:value "eligpercent" ]
           ]
         ];
         fhir:ClaimResponse.item.adjudication.value [ fhir:value "80.00"^^xsd:decimal ]
       ], [
         fhir:index 2;
         fhir:ClaimResponse.item.adjudication.category [
           fhir:CodeableConcept.coding [
             fhir:index 0;
             fhir:Coding.code [ fhir:value "benefit" ]
           ]
         ];
         fhir:ClaimResponse.item.adjudication.amount [
           fhir:Quantity.value [ fhir:value "600.00"^^xsd:decimal ];
           fhir:Quantity.system [ fhir:value "urn:iso:std:iso:4217" ];
           fhir:Quantity.code [ fhir:value "USD" ]
         ]
       ]
     ], [
       fhir:index 1;
       fhir:ClaimResponse.item.detail.detailSequence [ fhir:value "2"^^xsd:positiveInteger ];
       fhir:ClaimResponse.item.detail.adjudication [
         fhir:index 0;
         fhir:ClaimResponse.item.adjudication.category [
           fhir:CodeableConcept.coding [
             fhir:index 0;
             fhir:Coding.code [ fhir:value "eligible" ]
           ]
         ];
         fhir:ClaimResponse.item.adjudication.amount [
           fhir:Quantity.value [ fhir:value "0.00"^^xsd:decimal ];
           fhir:Quantity.system [ fhir:value "urn:iso:std:iso:4217" ];
           fhir:Quantity.code [ fhir:value "USD" ]
         ]
       ], [
         fhir:index 1;
         fhir:ClaimResponse.item.adjudication.category [
           fhir:CodeableConcept.coding [
             fhir:index 0;
             fhir:Coding.code [ fhir:value "benefit" ]
           ]
         ];
         fhir:ClaimResponse.item.adjudication.amount [
           fhir:Quantity.value [ fhir:value "0.00"^^xsd:decimal ];
           fhir:Quantity.system [ fhir:value "urn:iso:std:iso:4217" ];
           fhir:Quantity.code [ fhir:value "USD" ]
         ]
       ]
     ]
  ];
  fhir:ClaimResponse.addItem [
     fhir:index 0;
     fhir:ClaimResponse.addItem.itemSequence [
       fhir:value "1"^^xsd:positiveInteger;
       fhir:index 0
     ];
     fhir:ClaimResponse.addItem.service [
       fhir:CodeableConcept.coding [
         fhir:index 0;
         fhir:Coding.system [ fhir:value "http://example.org/fhir/oralservicecodes" ];
         fhir:Coding.code [ fhir:value "1101" ]
       ]
     ];
     fhir:ClaimResponse.addItem.modifier [
       fhir:index 0;
       fhir:CodeableConcept.coding [
         fhir:index 0;
         fhir:Coding.system [ fhir:value "http://example.org/fhir/modifiers" ];
         fhir:Coding.code [ fhir:value "x" ];
         fhir:Coding.display [ fhir:value "None" ]
       ]
     ];
     fhir:ClaimResponse.addItem.fee [
       fhir:Quantity.value [ fhir:value "135.57"^^xsd:decimal ];
       fhir:Quantity.system [ fhir:value "urn:iso:std:iso:4217" ];
       fhir:Quantity.code [ fhir:value "USD" ]
     ];
     fhir:ClaimResponse.addItem.noteNumber [
       fhir:value "101"^^xsd:positiveInteger;
       fhir:index 0
     ];
     fhir:ClaimResponse.addItem.adjudication [
       fhir:index 0;
       fhir:ClaimResponse.item.adjudication.category [
         fhir:CodeableConcept.coding [
           fhir:index 0;
           fhir:Coding.code [ fhir:value "eligible" ]
         ]
       ];
       fhir:ClaimResponse.item.adjudication.amount [
         fhir:Quantity.value [ fhir:value "100.00"^^xsd:decimal ];
         fhir:Quantity.system [ fhir:value "urn:iso:std:iso:4217" ];
         fhir:Quantity.code [ fhir:value "USD" ]
       ]
     ], [
       fhir:index 1;
       fhir:ClaimResponse.item.adjudication.category [
         fhir:CodeableConcept.coding [
           fhir:index 0;
           fhir:Coding.code [ fhir:value "copay" ]
         ]
       ];
       fhir:ClaimResponse.item.adjudication.amount [
         fhir:Quantity.value [ fhir:value "10.00"^^xsd:decimal ];
         fhir:Quantity.system [ fhir:value "urn:iso:std:iso:4217" ];
         fhir:Quantity.code [ fhir:value "USD" ]
       ]
     ], [
       fhir:index 2;
       fhir:ClaimResponse.item.adjudication.category [
         fhir:CodeableConcept.coding [
           fhir:index 0;
           fhir:Coding.code [ fhir:value "eligpercent" ]
         ]
       ];
       fhir:ClaimResponse.item.adjudication.value [ fhir:value "80.00"^^xsd:decimal ]
     ], [
       fhir:index 3;
       fhir:ClaimResponse.item.adjudication.category [
         fhir:CodeableConcept.coding [
           fhir:index 0;
           fhir:Coding.code [ fhir:value "benefit" ]
         ]
       ];
       fhir:ClaimResponse.item.adjudication.reason [
         fhir:CodeableConcept.coding [
           fhir:index 0;
           fhir:Coding.system [ fhir:value "http://hl7.org/fhir/adjudication-reason" ];
           fhir:Coding.code [ fhir:value "ar002" ];
           fhir:Coding.display [ fhir:value "Plan Limit Reached" ]
         ]
       ];
       fhir:ClaimResponse.item.adjudication.amount [
         fhir:Quantity.value [ fhir:value "72.00"^^xsd:decimal ];
         fhir:Quantity.system [ fhir:value "urn:iso:std:iso:4217" ];
         fhir:Quantity.code [ fhir:value "USD" ]
       ]
     ]
  ], [
     fhir:index 1;
     fhir:ClaimResponse.addItem.itemSequence [
       fhir:value "1"^^xsd:positiveInteger;
       fhir:index 0
     ];
     fhir:ClaimResponse.addItem.service [
       fhir:CodeableConcept.coding [
         fhir:index 0;
         fhir:Coding.system [ fhir:value "http://example.org/fhir/oralservicecodes" ];
         fhir:Coding.code [ fhir:value "2141" ];
         fhir:Coding.display [ fhir:value "Radiograph, bytewing" ]
       ]
     ];
     fhir:ClaimResponse.addItem.fee [
       fhir:Quantity.value [ fhir:value "35.57"^^xsd:decimal ];
       fhir:Quantity.system [ fhir:value "urn:iso:std:iso:4217" ];
       fhir:Quantity.code [ fhir:value "USD" ]
     ];
     fhir:ClaimResponse.addItem.adjudication [
       fhir:index 0;
       fhir:ClaimResponse.item.adjudication.category [
         fhir:CodeableConcept.coding [
           fhir:index 0;
           fhir:Coding.code [ fhir:value "eligible" ]
         ]
       ];
       fhir:ClaimResponse.item.adjudication.amount [
         fhir:Quantity.value [ fhir:value "35.57"^^xsd:decimal ];
         fhir:Quantity.system [ fhir:value "urn:iso:std:iso:4217" ];
         fhir:Quantity.code [ fhir:value "USD" ]
       ]
     ], [
       fhir:index 1;
       fhir:ClaimResponse.item.adjudication.category [
         fhir:CodeableConcept.coding [
           fhir:index 0;
           fhir:Coding.code [ fhir:value "eligpercent" ]
         ]
       ];
       fhir:ClaimResponse.item.adjudication.value [ fhir:value "80.00"^^xsd:decimal ]
     ], [
       fhir:index 2;
       fhir:ClaimResponse.item.adjudication.category [
         fhir:CodeableConcept.coding [
           fhir:index 0;
           fhir:Coding.code [ fhir:value "benefit" ]
         ]
       ];
       fhir:ClaimResponse.item.adjudication.amount [
         fhir:Quantity.value [ fhir:value "28.47"^^xsd:decimal ];
         fhir:Quantity.system [ fhir:value "urn:iso:std:iso:4217" ];
         fhir:Quantity.code [ fhir:value "USD" ]
       ]
     ]
  ], [
     fhir:index 2;
     fhir:ClaimResponse.addItem.itemSequence [
       fhir:value "3"^^xsd:positiveInteger;
       fhir:index 0
     ];
     fhir:ClaimResponse.addItem.detailSequence [
       fhir:value "2"^^xsd:positiveInteger;
       fhir:index 0
     ];
     fhir:ClaimResponse.addItem.service [
       fhir:CodeableConcept.coding [
         fhir:index 0;
         fhir:Coding.system [ fhir:value "http://example.org/fhir/oralservicecodes" ];
         fhir:Coding.code [ fhir:value "expense" ]
       ]
     ];
     fhir:ClaimResponse.addItem.modifier [
       fhir:index 0;
       fhir:CodeableConcept.coding [
         fhir:index 0;
         fhir:Coding.system [ fhir:value "http://example.org/fhir/modifiers" ];
         fhir:Coding.code [ fhir:value "x" ];
         fhir:Coding.display [ fhir:value "None" ]
       ]
     ];
     fhir:ClaimResponse.addItem.fee [
       fhir:Quantity.value [ fhir:value "350.00"^^xsd:decimal ];
       fhir:Quantity.system [ fhir:value "urn:iso:std:iso:4217" ];
       fhir:Quantity.code [ fhir:value "USD" ]
     ];
     fhir:ClaimResponse.addItem.noteNumber [
       fhir:value "101"^^xsd:positiveInteger;
       fhir:index 0
     ];
     fhir:ClaimResponse.addItem.adjudication [
       fhir:index 0;
       fhir:ClaimResponse.item.adjudication.category [
         fhir:CodeableConcept.coding [
           fhir:index 0;
           fhir:Coding.code [ fhir:value "eligible" ]
         ]
       ];
       fhir:ClaimResponse.item.adjudication.amount [
         fhir:Quantity.value [ fhir:value "350.00"^^xsd:decimal ];
         fhir:Quantity.system [ fhir:value "urn:iso:std:iso:4217" ];
         fhir:Quantity.code [ fhir:value "USD" ]
       ]
     ], [
       fhir:index 1;
       fhir:ClaimResponse.item.adjudication.category [
         fhir:CodeableConcept.coding [
           fhir:index 0;
           fhir:Coding.code [ fhir:value "eligpercent" ]
         ]
       ];
       fhir:ClaimResponse.item.adjudication.value [ fhir:value "80.00"^^xsd:decimal ]
     ], [
       fhir:index 2;
       fhir:ClaimResponse.item.adjudication.category [
         fhir:CodeableConcept.coding [
           fhir:index 0;
           fhir:Coding.code [ fhir:value "benefit" ]
         ]
       ];
       fhir:ClaimResponse.item.adjudication.amount [
         fhir:Quantity.value [ fhir:value "270.00"^^xsd:decimal ];
         fhir:Quantity.system [ fhir:value "urn:iso:std:iso:4217" ];
         fhir:Quantity.code [ fhir:value "USD" ]
       ]
     ]
  ];
  fhir:ClaimResponse.total [
     fhir:index 0;
     fhir:ClaimResponse.total.category [
       fhir:CodeableConcept.coding [
         fhir:index 0;
         fhir:Coding.code [ fhir:value "submitted" ]
       ]
     ];
     fhir:ClaimResponse.total.amount [
       fhir:Quantity.value [ fhir:value "1340.57"^^xsd:decimal ];
       fhir:Quantity.system [ fhir:value "urn:iso:std:iso:4217" ];
       fhir:Quantity.code [ fhir:value "USD" ]
     ]
  ], [
     fhir:index 1;
     fhir:ClaimResponse.total.category [
       fhir:CodeableConcept.coding [
         fhir:index 0;
         fhir:Coding.code [ fhir:value "benefit" ]
       ]
     ];
     fhir:ClaimResponse.total.amount [
       fhir:Quantity.value [ fhir:value "1054.47"^^xsd:decimal ];
       fhir:Quantity.system [ fhir:value "urn:iso:std:iso:4217" ];
       fhir:Quantity.code [ fhir:value "USD" ]
     ]
  ];
  fhir:ClaimResponse.payment [
     fhir:ClaimResponse.payment.type [
       fhir:CodeableConcept.coding [
         fhir:index 0;
         fhir:Coding.system [ fhir:value "http://hl7.org/fhir/ex-paymenttype" ];
         fhir:Coding.code [ fhir:value "complete" ]
       ]
     ];
     fhir:ClaimResponse.payment.date [ fhir:value "2014-08-31"^^xsd:date ];
     fhir:ClaimResponse.payment.amount [
       fhir:Quantity.value [ fhir:value "100.47"^^xsd:decimal ];
       fhir:Quantity.system [ fhir:value "urn:iso:std:iso:4217" ];
       fhir:Quantity.code [ fhir:value "USD" ]
     ];
     fhir:ClaimResponse.payment.identifier [
       fhir:Identifier.system [ fhir:value "http://www.BenefitsInc.com/fhir/paymentidentifier" ];
       fhir:Identifier.value [ fhir:value "201408-2-15507" ]
     ]
  ];
  fhir:ClaimResponse.processNote [
     fhir:index 0;
     fhir:ClaimResponse.processNote.number [ fhir:value "101"^^xsd:positiveInteger ];
     fhir:ClaimResponse.processNote.type [ fhir:value "print" ];
     fhir:ClaimResponse.processNote.text [ fhir:value "Package codes are not permitted. Codes replaced by Insurer." ];
     fhir:ClaimResponse.processNote.language [
       fhir:CodeableConcept.coding [
         fhir:index 0;
         fhir:Coding.system [ fhir:value "urn:ietf:bcp:47" ];
         fhir:Coding.code [ fhir:value "en-CA" ]
       ]
     ]
  ] .

<http://hl7.org/fhir/Patient/1> a fhir:Patient .

<http://hl7.org/fhir/Organization/1> a fhir:Organization .

# - ontology header ------------------------------------------------------------

<http://hl7.org/fhir/ClaimResponse/R3503.ttl> a owl:Ontology;
  owl:imports fhir:fhir.ttl;
  owl:versionIRI <http://build.fhir.org/ClaimResponse/R3503.ttl> .

# -------------------------------------------------------------------------------------

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.