Claim-example-oral-identifier.json

SOA Dental Claim using identifiers

{
  "resourceType": "Claim",
  "id": "100154",
  "text": {
    "status": "generated",
    "div": "<div xmlns=\"http://www.w3.org/1999/xhtml\">This example assumes a national health care scheme where patients, providers and organizations have known business identifiers.</div>"
  },
  "identifier": [
    {
      "system": "http://happyvalley.com/claim",
      "value": "12347"
    }
  ],
  "status": "active",
  "type": {
    "coding": [
      {
        "system": "http://hl7.org/fhir/ex-claimtype",
        "code": "oral"
      }
    ]
  },
  "use": "complete",
  "patient": {
    "identifier": {
      "system": "http://www.jurisdiction.com/nationalId",
      "value": "123AB345"
    }
  },
  "created": "2014-08-16",
  "insurer": {
    "identifier": {
      "system": "http://www.jurisdiction.com/insurers",
      "value": "123456"
    }
  },
  "organization": {
    "identifier": {
      "system": "http://www.jurisdiction.com/careorganizations",
      "value": "HOSP12345"
    }
  },
  "priority": {
    "coding": [
      {
        "code": "normal"
      }
    ]
  },
  "payee": {
    "type": {
      "coding": [
        {
          "code": "provider"
        }
      ]
    }
  },
  "careTeam": [
    {
      "sequence": 1,
      "provider": {
        "identifier": {
          "system": "http://www.jurisdiction.com/providerId",
          "value": "MD98765"
        }
      }
    }
  ],
  "diagnosis": [
    {
      "sequence": 1,
      "diagnosisCodeableConcept": {
        "coding": [
          {
            "code": "123456"
          }
        ]
      }
    }
  ],
  "insurance": [
    {
      "sequence": 1,
      "focal": true,
      "coverage": {
        "identifier": {
          "system": "http://www.jurisdiction.com/nationalplan",
          "value": "123AB345"
        }
      }
    }
  ],
  "item": [
    {
      "sequence": 1,
      "careTeamLinkId": [
        1
      ],
      "service": {
        "coding": [
          {
            "code": "1200"
          }
        ]
      },
      "servicedDate": "2014-08-16",
      "unitPrice": {
        "value": 135.57,
        "system": "urn:iso:std:iso:4217",
        "code": "USD"
      },
      "net": {
        "value": 135.57,
        "system": "urn:iso:std:iso:4217",
        "code": "USD"
      }
    }
  ]
}