FHIR © HL7.org  |  Server Home  |  Health Intersections FHIR Server v1.0.287  |  FHIR Version 4.0.0  | User: ANONYMOUS (Unknown)  

Resource "660152" Version "1" (Claim)

Tags:

XML or JSON representation . provenance for this resource

A human-readable rendering of the Vision Claim for Glasses

{
  "resourceType" : "Claim",
  "id" : "660152",
  "meta" : {
    "versionId" : "1",
    "lastUpdated" : "2018-12-14T02:01:33.864Z"
  },
  "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"
          }
        }
      ]
    }
  ]
}