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Resource "100152" Version "1" (Claim)

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XML or JSON representation . provenance for this resource

A human-readable rendering of the Oral Health Claim

{
  "resourceType" : "Claim",
  "id" : "100152",
  "meta" : {
    "versionId" : "1",
    "lastUpdated" : "2018-12-14T02:01:33.598Z"
  },
  "text" : {
    "status" : "generated",
    "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\">A human-readable rendering of the Oral Health Claim</div>"
  },
  "contained" : [
    {
      "resourceType" : "Organization",
      "id" : "org-insurer",
      "identifier" : [
        {
          "system" : "http://www.bindb.com/bin",
          "value" : "123456"
        }
      ]
    },
    {
      "resourceType" : "Organization",
      "id" : "org-org",
      "identifier" : [
        {
          "system" : "http://www.jurisdiction.com/oralhealthoffices",
          "value" : "3456"
        }
      ]
    },
    {
      "resourceType" : "Practitioner",
      "id" : "provider-1",
      "identifier" : [
        {
          "system" : "http://www.jurisdiction.com/oralhealthproviders",
          "value" : "123456789"
        }
      ]
    },
    {
      "resourceType" : "Patient",
      "id" : "patient-1",
      "name" : [
        {
          "use" : "official",
          "family" : "Donald",
          "given" : [
            "Duck"
          ]
        }
      ],
      "gender" : "male",
      "birthDate" : "1986-05-17",
      "address" : [
        {
          "use" : "home",
          "line" : [
            "1234 Main Street"
          ],
          "city" : "Vancouver",
          "postalCode" : "V2H1Y3",
          "country" : "CAD"
        }
      ]
    },
    {
      "resourceType" : "Coverage",
      "id" : "coverage-1",
      "identifier" : [
        {
          "system" : "http://benefitsinc.com/certificate",
          "value" : "12345"
        }
      ],
      "status" : "active",
      "type" : {
        "coding" : [
          {
            "system" : "http://terminology.hl7.org/CodeSystem/v3-ActCode",
            "code" : "EHCPOL"
          }
        ]
      },
      "subscriber" : {
        "reference" : "#patient-1"
      },
      "beneficiary" : {
        "reference" : "#patient-1"
      },
      "dependent" : "1",
      "relationship" : {
        "coding" : [
          {
            "code" : "self"
          }
        ]
      },
      "payor" : [
        {
          "identifier" : {
            "system" : "http://www.bindb.com/bin",
            "value" : "123456"
          }
        }
      ],
      "class" : [
        {
          "type" : {
            "coding" : [
              {
                "system" : "http://terminology.hl7.org/CodeSystem/coverage-class",
                "code" : "plan"
              }
            ]
          },
          "value" : "CBI35",
          "name" : "Corporate Baker's Inc. Plan#35"
        },
        {
          "type" : {
            "coding" : [
              {
                "system" : "http://terminology.hl7.org/CodeSystem/coverage-class",
                "code" : "subplan"
              }
            ]
          },
          "value" : "123",
          "name" : "Trainee Part-time Benefits"
        },
        {
          "type" : {
            "coding" : [
              {
                "system" : "http://terminology.hl7.org/CodeSystem/coverage-class",
                "code" : "sequence"
              }
            ]
          },
          "value" : "1"
        }
      ]
    }
  ],
  "identifier" : [
    {
      "system" : "http://happyvalley.com/claim",
      "value" : "12347"
    }
  ],
  "status" : "active",
  "type" : {
    "coding" : [
      {
        "system" : "http://terminology.hl7.org/CodeSystem/claim-type",
        "code" : "oral"
      }
    ]
  },
  "use" : "claim",
  "patient" : {
    "reference" : "#patient-1"
  },
  "created" : "2014-08-16",
  "insurer" : {
    "reference" : "#org-insurer"
  },
  "provider" : {
    "reference" : "#org-org"
  },
  "priority" : {
    "coding" : [
      {
        "code" : "normal"
      }
    ]
  },
  "payee" : {
    "type" : {
      "coding" : [
        {
          "code" : "provider"
        }
      ]
    }
  },
  "careTeam" : [
    {
      "sequence" : 1,
      "provider" : {
        "reference" : "#provider-1"
      }
    }
  ],
  "diagnosis" : [
    {
      "sequence" : 1,
      "diagnosisCodeableConcept" : {
        "coding" : [
          {
            "code" : "123456"
          }
        ]
      }
    }
  ],
  "insurance" : [
    {
      "sequence" : 1,
      "focal" : true,
      "coverage" : {
        "reference" : "#coverage-1"
      }
    }
  ],
  "item" : [
    {
      "sequence" : 1,
      "careTeamSequence" : [
        "1"
      ],
      "productOrService" : {
        "coding" : [
          {
            "code" : "1200"
          }
        ]
      },
      "servicedDate" : "2014-08-16",
      "unitPrice" : {
        "value" : 135.57,
        "currency" : "USD"
      },
      "net" : {
        "value" : 135.57,
        "currency" : "USD"
      }
    }
  ]
}