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Resource "100156" 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" : "100156",
  "meta" : {
    "versionId" : "1",
    "lastUpdated" : "2018-12-14T02:01:33.770Z"
  },
  "text" : {
    "status" : "generated",
    "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\">A human-readable rendering of the Oral Health Claim</div>"
  },
  "contained" : [
    {
      "resourceType" : "Device",
      "id" : "device-bridge"
    },
    {
      "resourceType" : "ServiceRequest",
      "id" : "referral",
      "status" : "active",
      "intent" : "order",
      "subject" : {
        "reference" : "Patient/1"
      }
    }
  ],
  "identifier" : [
    {
      "system" : "http://happyvalley.com/claim",
      "value" : "123466"
    }
  ],
  "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" : "Organization/2"
  },
  "provider" : {
    "reference" : "Organization/1"
  },
  "priority" : {
    "coding" : [
      {
        "code" : "normal"
      }
    ]
  },
  "related" : [
    {
      "claim" : {
        "reference" : "Claim/100151"
      },
      "relationship" : {
        "coding" : [
          {
            "system" : "http://terminology.hl7.org/CodeSystem/ex-relatedclaimrelationship",
            "code" : "associated"
          }
        ]
      },
      "reference" : {
        "value" : "CASE156746B"
      }
    }
  ],
  "payee" : {
    "type" : {
      "coding" : [
        {
          "system" : "http://terminology.hl7.org/CodeSystem/payeetype",
          "code" : "other"
        }
      ]
    },
    "party" : {
      "reference" : "RelatedPerson/peter"
    }
  },
  "referral" : {
    "reference" : "#referral"
  },
  "careTeam" : [
    {
      "sequence" : 1,
      "provider" : {
        "reference" : "Practitioner/example"
      }
    }
  ],
  "supportingInfo" : [
    {
      "sequence" : 1,
      "category" : {
        "coding" : [
          {
            "system" : "http://terminology.hl7.org/CodeSystem/claiminformationcategory",
            "code" : "prosthesis"
          }
        ]
      },
      "code" : {
        "coding" : [
          {
            "system" : "http://hl7.org/fhir/ex-oralprostho",
            "code" : "2",
            "display" : "Maryland Bridge"
          }
        ]
      },
      "timingDate" : "2001-04-07"
    }
  ],
  "procedure" : [
    {
      "sequence" : 1,
      "date" : "2014-07-04",
      "procedureCodeableConcept" : {
        "text" : "Resection of gum to increase exposed tooth."
      }
    }
  ],
  "insurance" : [
    {
      "sequence" : 1,
      "focal" : true,
      "coverage" : {
        "reference" : "Coverage/9876B1"
      }
    }
  ],
  "item" : [
    {
      "sequence" : 1,
      "careTeamSequence" : [
        "1"
      ],
      "informationSequence" : [
        "1"
      ],
      "productOrService" : {
        "coding" : [
          {
            "system" : "http://example.org/fhir/oralservicecodes",
            "code" : "67221",
            "display" : "Maryland Bridge"
          }
        ]
      },
      "servicedDate" : "2014-08-16",
      "locationCodeableConcept" : {
        "coding" : [
          {
            "system" : "http://terminology.hl7.org/CodeSystem/ex-serviceplace",
            "code" : "11"
          }
        ]
      },
      "unitPrice" : {
        "value" : 1400.00,
        "currency" : "USD"
      },
      "factor" : 0.75,
      "net" : {
        "value" : 1050.00,
        "currency" : "USD"
      },
      "udi" : [
        {
          "reference" : "#device-bridge"
        }
      ],
      "bodySite" : {
        "coding" : [
          {
            "system" : "http://fdi.org/fhir/oraltoothcodes",
            "code" : "01"
          }
        ]
      }
    },
    {
      "sequence" : 2,
      "careTeamSequence" : [
        "1"
      ],
      "productOrService" : {
        "coding" : [
          {
            "system" : "http://example.org/fhir/oralservicecodes",
            "code" : "21211"
          }
        ]
      },
      "servicedDate" : "2014-08-16",
      "locationCodeableConcept" : {
        "coding" : [
          {
            "system" : "http://terminology.hl7.org/CodeSystem/ex-serviceplace",
            "code" : "11"
          }
        ]
      },
      "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"
      ],
      "procedureSequence" : [
        "1"
      ],
      "productOrService" : {
        "coding" : [
          {
            "system" : "http://example.org/fhir/oralservicecodes",
            "code" : "27211"
          }
        ]
      },
      "servicedDate" : "2014-08-16",
      "locationCodeableConcept" : {
        "coding" : [
          {
            "system" : "http://terminology.hl7.org/CodeSystem/ex-serviceplace",
            "code" : "11"
          }
        ]
      },
      "unitPrice" : {
        "value" : 1100.00,
        "currency" : "USD"
      },
      "net" : {
        "value" : 1100.00,
        "currency" : "USD"
      },
      "bodySite" : {
        "coding" : [
          {
            "system" : "http://fdi.org/fhir/oraltoothcodes",
            "code" : "24"
          }
        ]
      },
      "detail" : [
        {
          "sequence" : 1,
          "productOrService" : {
            "coding" : [
              {
                "system" : "http://example.org/fhir/oralservicecodes",
                "code" : "27211"
              }
            ]
          },
          "unitPrice" : {
            "value" : 1000.00,
            "currency" : "USD"
          },
          "factor" : 0.75,
          "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"
          }
        }
      ]
    }
  ],
  "total" : {
    "value" : 2255.00,
    "currency" : "USD"
  }
}