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Resource "100153" 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" : "100153",
  "meta" : {
    "versionId" : "1",
    "lastUpdated" : "2018-12-14T02:01:33.661Z"
  },
  "text" : {
    "status" : "generated",
    "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\">A human-readable rendering of the Oral Health Claim</div>"
  },
  "identifier" : [
    {
      "system" : "http://happyvalley.com/claim",
      "value" : "12355"
    }
  ],
  "status" : "active",
  "type" : {
    "coding" : [
      {
        "system" : "http://terminology.hl7.org/CodeSystem/claim-type",
        "code" : "oral"
      }
    ]
  },
  "use" : "preauthorization",
  "patient" : {
    "reference" : "Patient/1"
  },
  "created" : "2015-03-16",
  "insurer" : {
    "reference" : "Organization/2"
  },
  "provider" : {
    "reference" : "Organization/1"
  },
  "priority" : {
    "coding" : [
      {
        "code" : "normal"
      }
    ]
  },
  "fundsReserve" : {
    "coding" : [
      {
        "code" : "provider"
      }
    ]
  },
  "payee" : {
    "type" : {
      "coding" : [
        {
          "code" : "provider"
        }
      ]
    }
  },
  "careTeam" : [
    {
      "sequence" : 1,
      "provider" : {
        "reference" : "Practitioner/example"
      }
    }
  ],
  "diagnosis" : [
    {
      "sequence" : 1,
      "diagnosisCodeableConcept" : {
        "coding" : [
          {
            "system" : "http://hl7.org/fhir/sid/icd-10",
            "code" : "123457"
          }
        ]
      }
    }
  ],
  "insurance" : [
    {
      "sequence" : 1,
      "focal" : true,
      "coverage" : {
        "reference" : "Coverage/9876B1"
      }
    }
  ],
  "item" : [
    {
      "sequence" : 1,
      "careTeamSequence" : [
        "1"
      ],
      "diagnosisSequence" : [
        "1"
      ],
      "productOrService" : {
        "coding" : [
          {
            "system" : "http://example.org/fhir/oralservicecodes",
            "code" : "ORTHPLAN"
          }
        ]
      },
      "servicedDate" : "2015-05-16",
      "unitPrice" : {
        "value" : 9000.00,
        "currency" : "USD"
      },
      "net" : {
        "value" : 9000.00,
        "currency" : "USD"
      },
      "detail" : [
        {
          "sequence" : 1,
          "productOrService" : {
            "coding" : [
              {
                "system" : "http://example.org/fhir/oralservicecodes",
                "code" : "ORTHOEXAM"
              }
            ]
          },
          "unitPrice" : {
            "value" : 1000.00,
            "currency" : "USD"
          },
          "net" : {
            "value" : 1000.00,
            "currency" : "USD"
          }
        },
        {
          "sequence" : 2,
          "productOrService" : {
            "coding" : [
              {
                "system" : "http://example.org/fhir/oralservicecodes",
                "code" : "ORTHODIAG"
              }
            ]
          },
          "unitPrice" : {
            "value" : 1500.00,
            "currency" : "USD"
          },
          "net" : {
            "value" : 1500.00,
            "currency" : "USD"
          }
        },
        {
          "sequence" : 3,
          "productOrService" : {
            "coding" : [
              {
                "system" : "http://example.org/fhir/oralservicecodes",
                "code" : "ORTHOINITIAL"
              }
            ]
          },
          "unitPrice" : {
            "value" : 500.00,
            "currency" : "USD"
          },
          "net" : {
            "value" : 500.00,
            "currency" : "USD"
          }
        },
        {
          "sequence" : 4,
          "productOrService" : {
            "coding" : [
              {
                "system" : "http://example.org/fhir/oralservicecodes",
                "code" : "ORTHOMONTHS"
              }
            ]
          },
          "quantity" : {
            "value" : 24
          }
        },
        {
          "sequence" : 5,
          "productOrService" : {
            "coding" : [
              {
                "system" : "http://example.org/fhir/oralservicecodes",
                "code" : "ORTHOPERIODIC"
              }
            ]
          },
          "quantity" : {
            "value" : 24
          },
          "unitPrice" : {
            "value" : 250.00,
            "currency" : "USD"
          },
          "net" : {
            "value" : 250.00,
            "currency" : "USD"
          }
        }
      ]
    },
    {
      "sequence" : 2,
      "careTeamSequence" : [
        "1"
      ],
      "productOrService" : {
        "coding" : [
          {
            "system" : "http://example.org/fhir/oralservicecodes",
            "code" : "21211"
          }
        ]
      },
      "servicedDate" : "2014-08-16",
      "unitPrice" : {
        "value" : 105.00,
        "currency" : "USD"
      },
      "net" : {
        "value" : 105.00,
        "currency" : "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"
      ],
      "productOrService" : {
        "coding" : [
          {
            "system" : "http://example.org/fhir/oralservicecodes",
            "code" : "27211"
          }
        ]
      },
      "servicedDate" : "2014-08-16",
      "unitPrice" : {
        "value" : 1100.00,
        "currency" : "USD"
      },
      "net" : {
        "value" : 1100.00,
        "currency" : "USD"
      },
      "bodySite" : {
        "coding" : [
          {
            "system" : "http://fdi.org/fhir/oraltoothcodes",
            "code" : "36"
          }
        ]
      },
      "detail" : [
        {
          "sequence" : 1,
          "productOrService" : {
            "coding" : [
              {
                "system" : "http://example.org/fhir/oralservicecodes",
                "code" : "27211"
              }
            ]
          },
          "unitPrice" : {
            "value" : 750.00,
            "currency" : "USD"
          },
          "net" : {
            "value" : 750.00,
            "currency" : "USD"
          }
        },
        {
          "sequence" : 2,
          "productOrService" : {
            "coding" : [
              {
                "system" : "http://example.org/fhir/oralservicecodes",
                "code" : "lab"
              }
            ]
          },
          "unitPrice" : {
            "value" : 350.00,
            "currency" : "USD"
          },
          "net" : {
            "value" : 350.00,
            "currency" : "USD"
          }
        }
      ]
    }
  ]
}