R6 Ballot (1st Draft)
This page is part of the FHIR Specification v6.0.0-ballot1: Release 6 Ballot (1st Draft) (see Ballot Notes). The current version is 5.0.0. For a full list of available versions, see the Directory of published versions 
| Financial Management Work Group | Maturity Level: N/A | Standards Status: Informative | Compartments: Device, Encounter, Patient, Practitioner, RelatedPerson |
Raw JSON (canonical form + also see JSON Format Specification)
Glasses Claim, 3 Tier, Secondary Coverage
Financial
{
"resourceType" : "Claim",
"id" : "660152",
"text" : {
"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\">A human-readable rendering of the Vision Claim for Glasses</div>"
},
"contained" : [{
"resourceType" : "Device",
"id" : "device-frame"
},
{
"resourceType" : "Device",
"id" : "device-lens"
}],
"identifier" : [{
"system" : "http://happysight.com/claim",
"value" : "6612347"
}],
"status" : "active",
"type" : {
"coding" : [{
"system" : "http://terminology.hl7.org/CodeSystem/claim-type",
"code" : "vision"
}]
},
"use" : "claim",
"patient" : {
"reference" : "Patient/1"
},
"created" : "2014-08-16",
"insurer" : {
"reference" : "Organization/2"
},
"provider" : {
"reference" : "Organization/1"
},
"priority" : {
"coding" : [{
"code" : "normal"
}]
},
"prescription" : {
"reference" : "http://www.optdocs.com/prescription/12345"
},
"payee" : {
"type" : {
"coding" : [{
"code" : "provider"
}]
}
},
"careTeam" : [{
"sequence" : 1,
"provider" : {
"reference" : "Practitioner/example"
}
}],
"diagnosis" : [{
"sequence" : 1,
"diagnosisCodeableConcept" : {
"coding" : [{
"code" : "654321"
}]
}
}],
"insurance" : [{
"sequence" : 1,
"focal" : false,
"coverage" : {
"reference" : "Coverage/9876B1"
},
"preAuthRef" : ["PR7652387237"],
"claimResponse" : {
"reference" : "ClaimResponse/R3500"
}
},
{
"sequence" : 2,
"focal" : true,
"coverage" : {
"reference" : "Coverage/9876B1"
},
"preAuthRef" : ["AB543GTD7567"]
}],
"item" : [{
"sequence" : 1,
"careTeamSequence" : [1],
"revenue" : {
"coding" : [{
"system" : "http://terminology.hl7.org/CodeSystem/ex-revenue-center",
"code" : "0010",
"display" : "Vision Clinic"
}]
},
"category" : {
"coding" : [{
"system" : "http://example.org/fhir/CodeSystem/benefit-subcategory",
"code" : "F6",
"display" : "Vision Coverage"
}]
},
"productOrService" : {
"coding" : [{
"system" : "http://example.org/fhir/CodeSystem/ex-visionservice",
"code" : "glasses"
}]
},
"modifier" : [{
"coding" : [{
"system" : "http://terminology.hl7.org/CodeSystem/modifiers",
"code" : "rooh"
}]
}],
"programCode" : [{
"coding" : [{
"system" : "http://terminology.hl7.org/CodeSystem/ex-programcode",
"code" : "none"
}]
}],
"servicedDate" : "2014-08-16",
"unitPrice" : {
"value" : 235.40,
"currency" : "USD"
},
"net" : {
"value" : 235.40,
"currency" : "USD"
},
"detail" : [{
"sequence" : 1,
"revenue" : {
"coding" : [{
"system" : "http://terminology.hl7.org/CodeSystem/ex-revenue-center",
"code" : "0010",
"display" : "Vision Clinic"
}]
},
"category" : {
"coding" : [{
"system" : "http://example.org/fhir/CodeSystem/benefit-subcategory",
"code" : "F6",
"display" : "Vision Coverage"
}]
},
"productOrService" : {
"coding" : [{
"system" : "http://example.org/fhir/CodeSystem/ex-visionservice",
"code" : "frame"
}]
},
"modifier" : [{
"coding" : [{
"system" : "http://terminology.hl7.org/CodeSystem/modifiers",
"code" : "rooh"
}]
}],
"unitPrice" : {
"value" : 100.00,
"currency" : "USD"
},
"factor" : 1.1,
"net" : {
"value" : 110.00,
"currency" : "USD"
},
"udi" : [{
"reference" : "#device-frame"
}]
},
{
"sequence" : 2,
"revenue" : {
"coding" : [{
"system" : "http://terminology.hl7.org/CodeSystem/ex-revenue-center",
"code" : "0010",
"display" : "Vision Clinic"
}]
},
"category" : {
"coding" : [{
"system" : "http://example.org/fhir/CodeSystem/benefit-subcategory",
"code" : "F6",
"display" : "Vision Coverage"
}]
},
"productOrService" : {
"coding" : [{
"system" : "http://example.org/fhir/CodeSystem/ex-visionservice",
"code" : "lens"
}]
},
"programCode" : [{
"coding" : [{
"system" : "http://terminology.hl7.org/CodeSystem/ex-programcode",
"code" : "none"
}]
}],
"quantity" : {
"value" : 2
},
"unitPrice" : {
"value" : 55.00,
"currency" : "USD"
},
"net" : {
"value" : 110.00,
"currency" : "USD"
},
"subDetail" : [{
"sequence" : 1,
"revenue" : {
"coding" : [{
"system" : "http://terminology.hl7.org/CodeSystem/ex-revenue-center",
"code" : "0010",
"display" : "Vision Clinic"
}]
},
"category" : {
"coding" : [{
"system" : "http://example.org/fhir/CodeSystem/benefit-subcategory",
"code" : "F6",
"display" : "Vision Coverage"
}]
},
"productOrService" : {
"coding" : [{
"system" : "http://example.org/fhir/CodeSystem/ex-visionservice",
"code" : "lens"
}]
},
"modifier" : [{
"coding" : [{
"system" : "http://terminology.hl7.org/CodeSystem/modifiers",
"code" : "rooh"
}]
}],
"programCode" : [{
"coding" : [{
"system" : "http://terminology.hl7.org/CodeSystem/ex-programcode",
"code" : "none"
}]
}],
"quantity" : {
"value" : 2
},
"unitPrice" : {
"value" : 30.00,
"currency" : "USD"
},
"factor" : 1.1,
"net" : {
"value" : 66.00,
"currency" : "USD"
},
"udi" : [{
"reference" : "#device-lens"
}]
},
{
"sequence" : 2,
"revenue" : {
"coding" : [{
"system" : "http://terminology.hl7.org/CodeSystem/ex-revenue-center",
"code" : "0010",
"display" : "Vision Clinic"
}]
},
"category" : {
"coding" : [{
"system" : "http://example.org/fhir/CodeSystem/benefit-subcategory",
"code" : "F6",
"display" : "Vision Coverage"
}]
},
"productOrService" : {
"coding" : [{
"system" : "http://example.org/fhir/CodeSystem/ex-visionservice",
"code" : "hardening"
}]
},
"modifier" : [{
"coding" : [{
"system" : "http://terminology.hl7.org/CodeSystem/modifiers",
"code" : "rooh"
}]
}],
"quantity" : {
"value" : 2
},
"unitPrice" : {
"value" : 15.00,
"currency" : "USD"
},
"factor" : 1.1,
"net" : {
"value" : 33.00,
"currency" : "USD"
}
},
{
"sequence" : 3,
"revenue" : {
"coding" : [{
"system" : "http://terminology.hl7.org/CodeSystem/ex-revenue-center",
"code" : "0010",
"display" : "Vision Clinic"
}]
},
"category" : {
"coding" : [{
"system" : "http://example.org/fhir/CodeSystem/benefit-subcategory",
"code" : "F6",
"display" : "Vision Coverage"
}]
},
"productOrService" : {
"coding" : [{
"system" : "http://example.org/fhir/CodeSystem/ex-visionservice",
"code" : "UV coating"
}]
},
"modifier" : [{
"coding" : [{
"system" : "http://terminology.hl7.org/CodeSystem/modifiers",
"code" : "rooh"
}]
}],
"quantity" : {
"value" : 2
},
"unitPrice" : {
"value" : 5.00,
"currency" : "USD"
},
"factor" : 1.1,
"net" : {
"value" : 11.00,
"currency" : "USD"
}
}]
},
{
"sequence" : 3,
"revenue" : {
"coding" : [{
"system" : "http://terminology.hl7.org/CodeSystem/ex-revenue-center",
"code" : "0010",
"display" : "Vision Clinic"
}]
},
"category" : {
"coding" : [{
"system" : "http://example.org/fhir/CodeSystem/benefit-subcategory",
"code" : "F6",
"display" : "Vision Coverage"
}]
},
"productOrService" : {
"coding" : [{
"system" : "http://example.org/fhir/CodeSystem/ex-visionservice",
"code" : "fst"
}]
},
"unitPrice" : {
"value" : 220.00,
"currency" : "USD"
},
"factor" : 0.07,
"net" : {
"value" : 15.40,
"currency" : "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.
FHIR ®© HL7.org 2011+. FHIR R6 hl7.fhir.core#6.0.0-ballot1 generated on Mon, Dec 18, 2023 15:16+1100.
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