FHIR © HL7.org  |  Server Home  |  Health Intersections FHIR Server v1.0.279  |  FHIR Version 4.0.0  | User: ANONYMOUS (Unknown)  

History Record

XML or JSON representation

Links: First Previous Next Last  (17 found). Search: http://tx.fhir.org/r4/Claim/_history?&_prior=2019-03-19T15:43:14.643Z&_format=text/xhtml&history-id=44bbfebc-5171-421e-92e5-e77e05d216 

Claim "MED-00050" Version "1"

Tags: (no tags)  +

This Resource , XML or JSON representation, or the full version history.. provenance for this resource
Updated: by

A human-readable rendering of a CMS 1500 Claim

{
  "resourceType" : "Claim",
  "id" : "MED-00050",
  "meta" : {
    "versionId" : "1",
    "lastUpdated" : "2018-12-14T02:01:34.098Z"
  },
  "text" : {
    "status" : "generated",
    "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\">A human-readable rendering of a CMS 1500 Claim</div>"
  },
  "contained" : [
    {
      "resourceType" : "Patient",
      "id" : "patient-1",
      "name" : [
        {
          "use" : "official",
          "family" : "Ashcraft",
          "given" : [
            "Alvina"
          ]
        }
      ],
      "gender" : "female",
      "birthDate" : "1954-06-11",
      "address" : [
        {
          "use" : "home",
          "line" : [
            "123 Main Street"
          ],
          "city" : "Portland",
          "state" : "OR",
          "postalCode" : "97125",
          "country" : "USA"
        }
      ]
    },
    {
      "resourceType" : "Coverage",
      "id" : "coverage-1",
      "identifier" : [
        {
          "system" : "http://benefitsinc.com/certificate",
          "value" : "10138556"
        }
      ],
      "status" : "active",
      "type" : {
        "coding" : [
          {
            "system" : "http://terminology.hl7.org/CodeSystem/v3-ActCode",
            "code" : "HIP",
            "display" : "health insurance plan policy"
          }
        ]
      },
      "subscriber" : {
        "reference" : "#patient-1"
      },
      "beneficiary" : {
        "reference" : "#patient-1"
      },
      "relationship" : {
        "coding" : [
          {
            "code" : "self"
          }
        ]
      },
      "period" : {
        "start" : "2015-01-01T00:00:00-07:00",
        "end" : "2016-01-01T00:00:00-07:00"
      },
      "payor" : [
        {
          "identifier" : {
            "system" : "http://www.bindb.com/bin",
            "value" : "123456"
          },
          "display" : "Humana Inc."
        }
      ],
      "class" : [
        {
          "type" : {
            "coding" : [
              {
                "system" : "http://terminology.hl7.org/CodeSystem/coverage-class",
                "code" : "group"
              }
            ]
          },
          "value" : "80902206"
        }
      ]
    }
  ],
  "identifier" : [
    {
      "system" : "http://CedarArmsMedicalCenter.com/claim",
      "value" : "MED-00050"
    }
  ],
  "status" : "active",
  "type" : {
    "coding" : [
      {
        "system" : "http://terminology.hl7.org/CodeSystem/claim-type",
        "code" : "institutional"
      }
    ]
  },
  "subType" : {
    "coding" : [
      {
        "system" : "https://www.cms.gov/codes/billtype",
        "code" : "831",
        "display" : "Hospital Outpatient Surgery performed in an Ambulatory ​Surgical Center"
      }
    ]
  },
  "use" : "claim",
  "patient" : {
    "reference" : "#patient-1"
  },
  "created" : "2015-10-16T00:00:00-07:00",
  "insurer" : {
    "identifier" : {
      "system" : "http://www.bindb.com/bin",
      "value" : "123456"
    },
    "display" : "Humana Inc."
  },
  "provider" : {
    "reference" : "Organization/1"
  },
  "priority" : {
    "coding" : [
      {
        "code" : "normal"
      }
    ]
  },
  "payee" : {
    "type" : {
      "coding" : [
        {
          "system" : "http://terminology.hl7.org/CodeSystem/payeetype",
          "code" : "provider"
        }
      ]
    },
    "party" : {
      "reference" : "Organization/1"
    }
  },
  "careTeam" : [
    {
      "sequence" : 1,
      "provider" : {
        "reference" : "Practitioner/example"
      }
    }
  ],
  "supportingInfo" : [
    {
      "sequence" : 1,
      "category" : {
        "coding" : [
          {
            "system" : "http://terminology.hl7.org/CodeSystem/claiminformationcategory",
            "code" : "hospitalized"
          }
        ]
      },
      "timingPeriod" : {
        "start" : "2015-10-01T00:00:00-07:00",
        "end" : "2015-10-05T00:00:00-07:00"
      }
    },
    {
      "sequence" : 2,
      "category" : {
        "coding" : [
          {
            "system" : "http://terminology.hl7.org/CodeSystem/claiminformationcategory",
            "code" : "discharge"
          }
        ]
      },
      "code" : {
        "coding" : [
          {
            "system" : "https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/SE0801.pdf",
            "code" : "01",
            "display" : "Discharge to Home or Self Care"
          }
        ]
      }
    }
  ],
  "diagnosis" : [
    {
      "sequence" : 1,
      "diagnosisCodeableConcept" : {
        "coding" : [
          {
            "system" : "http://hl7.org/fhir/sid/icd-10",
            "code" : "M96.1",
            "display" : "Postlaminectomy syndrome"
          }
        ]
      }
    },
    {
      "sequence" : 2,
      "diagnosisCodeableConcept" : {
        "coding" : [
          {
            "system" : "http://hl7.org/fhir/sid/icd-10",
            "code" : "G89.4",
            "display" : "Chronic pain syndrome"
          }
        ]
      }
    },
    {
      "sequence" : 3,
      "diagnosisCodeableConcept" : {
        "coding" : [
          {
            "system" : "http://hl7.org/fhir/sid/icd-10",
            "code" : "M53.88",
            "display" : "Other specified dorsopathies, sacral and sacrococcygeal region"
          }
        ]
      }
    },
    {
      "sequence" : 4,
      "diagnosisCodeableConcept" : {
        "coding" : [
          {
            "system" : "http://hl7.org/fhir/sid/icd-10",
            "code" : "M47.816",
            "display" : "Spondylosis without myelopathy or radiculopathy, lumbar region"
          }
        ]
      }
    }
  ],
  "insurance" : [
    {
      "sequence" : 1,
      "focal" : true,
      "identifier" : {
        "system" : "http://CedarArmsMedicalCenter.com/claim",
        "value" : "MED-00050"
      },
      "coverage" : {
        "reference" : "#coverage-1"
      }
    }
  ],
  "item" : [
    {
      "sequence" : 1,
      "careTeamSequence" : [
        "1"
      ],
      "diagnosisSequence" : [
        "2",
        "4"
      ],
      "informationSequence" : [
        "1"
      ],
      "productOrService" : {
        "coding" : [
          {
            "system" : "http://www.ama-assn.org/go/cpt",
            "code" : "62264",
            "display" : "Surgical Procedures on the Spine and Spinal Cord"
          }
        ]
      },
      "servicedDate" : "2015-10-13",
      "locationCodeableConcept" : {
        "coding" : [
          {
            "system" : "https://www.cms.gov/medicare/coding/place-of-service-codes/place_of_service_code_set.html",
            "code" : "24",
            "display" : "Ambulatory Surgical Center"
          }
        ]
      },
      "unitPrice" : {
        "value" : 12500.00,
        "currency" : "USD"
      },
      "net" : {
        "value" : 12500.00,
        "currency" : "USD"
      }
    }
  ],
  "total" : {
    "value" : 12500.00,
    "currency" : "USD"
  }
}

Claim "960151" Version "1"

Tags: (no tags)  +

This Resource , XML or JSON representation, or the full version history.. provenance for this resource
Updated: by

A human-readable rendering of the Claim

{
  "resourceType" : "Claim",
  "id" : "960151",
  "meta" : {
    "versionId" : "1",
    "lastUpdated" : "2018-12-14T02:01:34.067Z"
  },
  "text" : {
    "status" : "generated",
    "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\">A human-readable rendering of the Claim</div>"
  },
  "identifier" : [
    {
      "system" : "http://happyhospital.com/claim",
      "value" : "96123451"
    }
  ],
  "status" : "active",
  "type" : {
    "coding" : [
      {
        "system" : "http://terminology.hl7.org/CodeSystem/claim-type",
        "code" : "institutional"
      }
    ]
  },
  "use" : "claim",
  "patient" : {
    "reference" : "Patient/1"
  },
  "billablePeriod" : {
    "start" : "2014-08-15",
    "end" : "2014-08-16"
  },
  "created" : "2014-08-16",
  "enterer" : {
    "identifier" : {
      "system" : "http://jurisdiction.org/facilities/HOSP1234/users",
      "value" : "UC1234"
    }
  },
  "insurer" : {
    "reference" : "Organization/2"
  },
  "provider" : {
    "identifier" : {
      "system" : "http://npid.org/providerid",
      "value" : "NJ12345"
    }
  },
  "priority" : {
    "coding" : [
      {
        "code" : "normal"
      }
    ]
  },
  "payee" : {
    "type" : {
      "coding" : [
        {
          "code" : "provider"
        }
      ]
    }
  },
  "facility" : {
    "identifier" : {
      "system" : "http://jurisdiction.org/facilities",
      "value" : "HOSP1234"
    }
  },
  "careTeam" : [
    {
      "sequence" : 1,
      "provider" : {
        "reference" : "Practitioner/example"
      },
      "responsible" : true,
      "role" : {
        "coding" : [
          {
            "system" : "http://example.org/fhir/CodeSystem/claim-careteamrole",
            "code" : "primary"
          }
        ]
      },
      "qualification" : {
        "coding" : [
          {
            "system" : "http://example.org/fhir/CodeSystem/provider-qualification",
            "code" : "physician"
          }
        ]
      }
    }
  ],
  "supportingInfo" : [
    {
      "sequence" : 1,
      "category" : {
        "coding" : [
          {
            "system" : "http://terminology.hl7.org/CodeSystem/claiminformationcategory",
            "code" : "employmentimpacted"
          }
        ]
      },
      "timingPeriod" : {
        "start" : "2014-08-16",
        "end" : "2014-08-16"
      }
    },
    {
      "sequence" : 2,
      "category" : {
        "coding" : [
          {
            "system" : "http://terminology.hl7.org/CodeSystem/claiminformationcategory",
            "code" : "hospitalized"
          }
        ]
      },
      "timingPeriod" : {
        "start" : "2014-08-15",
        "end" : "2014-08-16"
      }
    }
  ],
  "diagnosis" : [
    {
      "sequence" : 1,
      "diagnosisCodeableConcept" : {
        "coding" : [
          {
            "code" : "654456"
          }
        ]
      },
      "type" : [
        {
          "coding" : [
            {
              "system" : "http://terminology.hl7.org/CodeSystem/ex-diagnosistype",
              "code" : "admitting"
            }
          ]
        }
      ],
      "packageCode" : {
        "coding" : [
          {
            "system" : "http://terminology.hl7.org/CodeSystem/ex-diagnosisrelatedgroup",
            "code" : "400",
            "display" : "Head trauma - concussion"
          }
        ]
      }
    }
  ],
  "insurance" : [
    {
      "sequence" : 1,
      "focal" : true,
      "coverage" : {
        "reference" : "Coverage/9876B1"
      },
      "businessArrangement" : "BA987123",
      "preAuthRef" : [
        "PA2014G56473"
      ]
    }
  ],
  "accident" : {
    "date" : "2014-07-09",
    "type" : {
      "coding" : [
        {
          "system" : "http://terminology.hl7.org/CodeSystem/v3-ActIncidentCode",
          "code" : "SPT",
          "display" : "Sporting Accident"
        }
      ]
    },
    "locationAddress" : {
      "text" : "Grouse Mountain Ski Hill"
    }
  },
  "item" : [
    {
      "sequence" : 1,
      "careTeamSequence" : [
        "1"
      ],
      "productOrService" : {
        "coding" : [
          {
            "system" : "http://hl7.org/fhir/ex-serviceproduct",
            "code" : "exam"
          }
        ]
      },
      "servicedDate" : "2014-08-16",
      "unitPrice" : {
        "value" : 125.00,
        "currency" : "USD"
      },
      "net" : {
        "value" : 125.00,
        "currency" : "USD"
      }
    }
  ],
  "total" : {
    "value" : 125.00,
    "currency" : "USD"
  }
}

Claim "960150" Version "1"

Tags: (no tags)  +

This Resource , XML or JSON representation, or the full version history.. provenance for this resource
Updated: by

A human-readable rendering of the Claim

{
  "resourceType" : "Claim",
  "id" : "960150",
  "meta" : {
    "versionId" : "1",
    "lastUpdated" : "2018-12-14T02:01:34.036Z"
  },
  "text" : {
    "status" : "generated",
    "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\">A human-readable rendering of the Claim</div>"
  },
  "identifier" : [
    {
      "system" : "http://happyhospital.com/claim",
      "value" : "9612345"
    }
  ],
  "status" : "active",
  "type" : {
    "coding" : [
      {
        "system" : "http://terminology.hl7.org/CodeSystem/claim-type",
        "code" : "institutional"
      }
    ]
  },
  "subType" : {
    "coding" : [
      {
        "system" : "http://terminology.hl7.org/CodeSystem/ex-claimsubtype",
        "code" : "emergency"
      }
    ]
  },
  "use" : "claim",
  "patient" : {
    "reference" : "Patient/1"
  },
  "created" : "2014-08-16",
  "enterer" : {
    "identifier" : {
      "system" : "http://jurisdiction.org/facilities/HOSP1234/users",
      "value" : "UC1234"
    }
  },
  "insurer" : {
    "reference" : "Organization/2"
  },
  "provider" : {
    "reference" : "Organization/1"
  },
  "priority" : {
    "coding" : [
      {
        "code" : "normal"
      }
    ]
  },
  "payee" : {
    "type" : {
      "coding" : [
        {
          "code" : "provider"
        }
      ]
    }
  },
  "facility" : {
    "identifier" : {
      "system" : "http://jurisdiction.org/facilities",
      "value" : "HOSP1234"
    }
  },
  "careTeam" : [
    {
      "sequence" : 1,
      "provider" : {
        "reference" : "Practitioner/example"
      }
    }
  ],
  "diagnosis" : [
    {
      "sequence" : 1,
      "diagnosisCodeableConcept" : {
        "coding" : [
          {
            "code" : "654456"
          }
        ]
      }
    }
  ],
  "procedure" : [
    {
      "sequence" : 1,
      "type" : [
        {
          "coding" : [
            {
              "code" : "primary"
            }
          ]
        }
      ],
      "date" : "2014-08-16",
      "procedureCodeableConcept" : {
        "coding" : [
          {
            "code" : "SDI9901"
          }
        ],
        "text" : "Subcutaneous diagnostic implant"
      },
      "udi" : [
        {
          "reference" : "Device/example"
        }
      ]
    }
  ],
  "insurance" : [
    {
      "sequence" : 1,
      "focal" : true,
      "coverage" : {
        "reference" : "Coverage/9876B1"
      }
    }
  ],
  "item" : [
    {
      "sequence" : 1,
      "careTeamSequence" : [
        "1"
      ],
      "productOrService" : {
        "coding" : [
          {
            "system" : "http://hl7.org/fhir/ex-serviceproduct",
            "code" : "exam"
          }
        ]
      },
      "servicedDate" : "2014-08-16",
      "unitPrice" : {
        "value" : 125.00,
        "currency" : "USD"
      },
      "net" : {
        "value" : 125.00,
        "currency" : "USD"
      },
      "encounter" : [
        {
          "reference" : "Encounter/example"
        }
      ]
    }
  ],
  "total" : {
    "value" : 125.00,
    "currency" : "USD"
  }
}

Claim "860150" Version "1"

Tags: (no tags)  +

This Resource , XML or JSON representation, or the full version history.. provenance for this resource
Updated: by

A human-readable rendering of the Claim

{
  "resourceType" : "Claim",
  "id" : "860150",
  "meta" : {
    "versionId" : "1",
    "lastUpdated" : "2018-12-14T02:01:34.004Z"
  },
  "text" : {
    "status" : "generated",
    "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\">A human-readable rendering of the Claim</div>"
  },
  "identifier" : [
    {
      "system" : "http://happypdocs.com/claim",
      "value" : "8612345"
    }
  ],
  "status" : "active",
  "type" : {
    "coding" : [
      {
        "system" : "http://terminology.hl7.org/CodeSystem/claim-type",
        "code" : "professional"
      }
    ]
  },
  "use" : "claim",
  "patient" : {
    "reference" : "Patient/1"
  },
  "created" : "2014-08-16",
  "insurer" : {
    "reference" : "Organization/2"
  },
  "provider" : {
    "reference" : "Organization/1"
  },
  "priority" : {
    "coding" : [
      {
        "code" : "normal"
      }
    ]
  },
  "payee" : {
    "type" : {
      "coding" : [
        {
          "code" : "provider"
        }
      ]
    }
  },
  "careTeam" : [
    {
      "sequence" : 1,
      "provider" : {
        "reference" : "Practitioner/example"
      }
    }
  ],
  "diagnosis" : [
    {
      "sequence" : 1,
      "diagnosisCodeableConcept" : {
        "coding" : [
          {
            "code" : "654456"
          }
        ]
      }
    }
  ],
  "insurance" : [
    {
      "sequence" : 1,
      "focal" : true,
      "coverage" : {
        "reference" : "Coverage/9876B1"
      }
    }
  ],
  "item" : [
    {
      "sequence" : 1,
      "careTeamSequence" : [
        "1"
      ],
      "productOrService" : {
        "coding" : [
          {
            "system" : "http://hl7.org/fhir/ex-serviceproduct",
            "code" : "exam"
          }
        ]
      },
      "servicedDate" : "2014-08-16",
      "unitPrice" : {
        "value" : 75.00,
        "currency" : "USD"
      },
      "net" : {
        "value" : 75.00,
        "currency" : "USD"
      }
    }
  ]
}

Claim "760152" Version "1"

Tags: (no tags)  +

This Resource , XML or JSON representation, or the full version history.. provenance for this resource
Updated: by

A human-readable rendering of the Pharmacy Claim

{
  "resourceType" : "Claim",
  "id" : "760152",
  "meta" : {
    "versionId" : "1",
    "lastUpdated" : "2018-12-14T02:01:33.973Z"
  },
  "text" : {
    "status" : "generated",
    "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\">A human-readable rendering of the Pharmacy Claim</div>"
  },
  "identifier" : [
    {
      "system" : "http://happypharma.com/claim",
      "value" : "7612345"
    }
  ],
  "status" : "active",
  "type" : {
    "coding" : [
      {
        "system" : "http://terminology.hl7.org/CodeSystem/claim-type",
        "code" : "pharmacy"
      }
    ]
  },
  "use" : "claim",
  "patient" : {
    "reference" : "Patient/1"
  },
  "created" : "2014-08-16",
  "insurer" : {
    "reference" : "Organization/2"
  },
  "provider" : {
    "reference" : "Organization/1"
  },
  "priority" : {
    "coding" : [
      {
        "code" : "stat"
      }
    ]
  },
  "payee" : {
    "type" : {
      "coding" : [
        {
          "code" : "provider"
        }
      ]
    }
  },
  "careTeam" : [
    {
      "sequence" : 1,
      "provider" : {
        "reference" : "Practitioner/example"
      }
    }
  ],
  "supportingInfo" : [
    {
      "sequence" : 1,
      "category" : {
        "coding" : [
          {
            "code" : "pharmacyrefill"
          }
        ]
      },
      "code" : {
        "coding" : [
          {
            "system" : "http://example.org/fhir/CodeSystem/pharmacy-refill",
            "code" : "new"
          }
        ]
      }
    },
    {
      "sequence" : 2,
      "category" : {
        "coding" : [
          {
            "code" : "pharmacyinformation"
          }
        ]
      },
      "code" : {
        "coding" : [
          {
            "system" : "http://example.org/fhir/CodeSystem/pharmacy-information",
            "code" : "refillsremaining"
          }
        ]
      },
      "valueQuantity" : {
        "value" : 0
      }
    },
    {
      "sequence" : 3,
      "category" : {
        "coding" : [
          {
            "code" : "pharmacyinformation"
          }
        ]
      },
      "code" : {
        "coding" : [
          {
            "system" : "http://example.org/fhir/CodeSystem/pharmacy-information",
            "code" : "dayssupply"
          }
        ]
      },
      "valueQuantity" : {
        "value" : 10
      }
    },
    {
      "sequence" : 4,
      "category" : {
        "coding" : [
          {
            "code" : "pharmacy"
          }
        ]
      },
      "code" : {
        "coding" : [
          {
            "system" : "http://example.org/fhir/CodeSystem/pharmacy-form",
            "code" : "capsule"
          }
        ]
      }
    }
  ],
  "diagnosis" : [
    {
      "sequence" : 1,
      "diagnosisCodeableConcept" : {
        "coding" : [
          {
            "code" : "654456"
          }
        ]
      }
    }
  ],
  "insurance" : [
    {
      "sequence" : 1,
      "focal" : true,
      "coverage" : {
        "reference" : "Coverage/9876B1"
      }
    }
  ],
  "item" : [
    {
      "sequence" : 1,
      "careTeamSequence" : [
        "1"
      ],
      "informationSequence" : [
        "1",
        "2",
        "3",
        "4"
      ],
      "productOrService" : {
        "coding" : [
          {
            "system" : "http://localdruglist.org",
            "code" : "compound",
            "display" : "Custom compound"
          }
        ]
      },
      "servicedDate" : "2014-08-16",
      "quantity" : {
        "value" : 30,
        "unit" : "TAB",
        "system" : "http://unitsofmeasure.org",
        "code" : "TAB"
      },
      "net" : {
        "value" : 155.00,
        "currency" : "USD"
      },
      "detail" : [
        {
          "sequence" : 1,
          "productOrService" : {
            "coding" : [
              {
                "system" : "http://localdruglist.org",
                "code" : "44001",
                "display" : "Acetaminophen 250mg"
              }
            ]
          },
          "quantity" : {
            "value" : 250,
            "unit" : "mg"
          },
          "net" : {
            "value" : 20.00,
            "currency" : "USD"
          },
          "subDetail" : [
            {
              "sequence" : 1,
              "productOrService" : {
                "coding" : [
                  {
                    "system" : "http://hl7.org/fhir/ex-pharmaservice",
                    "code" : "drugcost"
                  }
                ]
              },
              "net" : {
                "value" : 20.00,
                "currency" : "USD"
              }
            }
          ]
        },
        {
          "sequence" : 2,
          "productOrService" : {
            "coding" : [
              {
                "system" : "http://localdruglist.org",
                "code" : "44035",
                "display" : "Phenacetin 50mg"
              }
            ]
          },
          "quantity" : {
            "value" : 50,
            "unit" : "mg"
          },
          "net" : {
            "value" : 25.00,
            "currency" : "USD"
          },
          "subDetail" : [
            {
              "sequence" : 1,
              "productOrService" : {
                "coding" : [
                  {
                    "system" : "http://hl7.org/fhir/ex-pharmaservice",
                    "code" : "drugcost"
                  }
                ]
              },
              "net" : {
                "value" : 25.00,
                "currency" : "USD"
              }
            }
          ]
        },
        {
          "sequence" : 3,
          "productOrService" : {
            "coding" : [
              {
                "system" : "http://localdruglist.org",
                "code" : "44057",
                "display" : "Codeine 25mg"
              }
            ]
          },
          "quantity" : {
            "value" : 25,
            "unit" : "mg"
          },
          "net" : {
            "value" : 28.00,
            "currency" : "USD"
          },
          "subDetail" : [
            {
              "sequence" : 1,
              "productOrService" : {
                "coding" : [
                  {
                    "system" : "http://hl7.org/fhir/ex-pharmaservice",
                    "code" : "drugcost"
                  }
                ]
              },
              "net" : {
                "value" : 28.00,
                "currency" : "USD"
              }
            }
          ]
        },
        {
          "sequence" : 2,
          "productOrService" : {
            "coding" : [
              {
                "system" : "http://hl7.org/fhir/ex-pharmaservice",
                "code" : "markup"
              }
            ]
          },
          "net" : {
            "value" : 22.00,
            "currency" : "USD"
          }
        },
        {
          "sequence" : 3,
          "productOrService" : {
            "coding" : [
              {
                "system" : "http://hl7.org/fhir/ex-pharmaservice",
                "code" : "compoundfee"
              }
            ]
          },
          "net" : {
            "value" : 60.00,
            "currency" : "USD"
          }
        }
      ]
    }
  ],
  "total" : {
    "value" : 155.00,
    "currency" : "USD"
  }
}

Claim "760151" Version "1"

Tags: (no tags)  +

This Resource , XML or JSON representation, or the full version history.. provenance for this resource
Updated: by

A human-readable rendering of the Pharmacy Claim

{
  "resourceType" : "Claim",
  "id" : "760151",
  "meta" : {
    "versionId" : "1",
    "lastUpdated" : "2018-12-14T02:01:33.942Z"
  },
  "text" : {
    "status" : "generated",
    "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\">A human-readable rendering of the Pharmacy Claim</div>"
  },
  "identifier" : [
    {
      "system" : "http://happypharma.com/claim",
      "value" : "7612345"
    }
  ],
  "status" : "active",
  "type" : {
    "coding" : [
      {
        "system" : "http://terminology.hl7.org/CodeSystem/claim-type",
        "code" : "pharmacy"
      }
    ]
  },
  "use" : "claim",
  "patient" : {
    "reference" : "Patient/1"
  },
  "created" : "2014-08-16",
  "insurer" : {
    "reference" : "Organization/2"
  },
  "provider" : {
    "reference" : "Organization/1"
  },
  "priority" : {
    "coding" : [
      {
        "code" : "stat"
      }
    ]
  },
  "prescription" : {
    "reference" : "http://pharmacy.org/MedicationRequest/AB1234G"
  },
  "originalPrescription" : {
    "reference" : "http://pharmacy.org/MedicationRequest/AB1202B"
  },
  "payee" : {
    "type" : {
      "coding" : [
        {
          "code" : "provider"
        }
      ]
    }
  },
  "careTeam" : [
    {
      "sequence" : 1,
      "provider" : {
        "reference" : "Practitioner/example"
      }
    }
  ],
  "supportingInfo" : [
    {
      "sequence" : 1,
      "category" : {
        "coding" : [
          {
            "code" : "pharmacyrefill"
          }
        ]
      },
      "code" : {
        "coding" : [
          {
            "system" : "http://example.org/fhir/CodeSystem/pharmacy-refill",
            "code" : "new"
          }
        ]
      }
    },
    {
      "sequence" : 2,
      "category" : {
        "coding" : [
          {
            "code" : "pharmacyinformation"
          }
        ]
      },
      "code" : {
        "coding" : [
          {
            "system" : "http://example.org/fhir/CodeSystem/pharmacy-information",
            "code" : "refillsremaining"
          }
        ]
      },
      "valueQuantity" : {
        "value" : 2
      }
    },
    {
      "sequence" : 3,
      "category" : {
        "coding" : [
          {
            "code" : "pharmacyinformation"
          }
        ]
      },
      "code" : {
        "coding" : [
          {
            "system" : "http://example.org/fhir/CodeSystem/pharmacy-information",
            "code" : "dayssupply"
          }
        ]
      },
      "valueQuantity" : {
        "value" : 90
      }
    }
  ],
  "diagnosis" : [
    {
      "sequence" : 1,
      "diagnosisCodeableConcept" : {
        "coding" : [
          {
            "code" : "654456"
          }
        ]
      }
    }
  ],
  "insurance" : [
    {
      "sequence" : 1,
      "focal" : true,
      "coverage" : {
        "reference" : "Coverage/9876B1"
      }
    }
  ],
  "item" : [
    {
      "sequence" : 1,
      "careTeamSequence" : [
        "1"
      ],
      "informationSequence" : [
        "1",
        "2",
        "3"
      ],
      "productOrService" : {
        "coding" : [
          {
            "system" : "http://www.nlm.nih.gov/research/umls/rxnorm",
            "code" : "562721",
            "display" : "Alprazolam 0.25mg (Xanax)"
          }
        ]
      },
      "servicedDate" : "2014-08-16",
      "quantity" : {
        "value" : 90,
        "unit" : "TAB",
        "system" : "http://unitsofmeasure.org",
        "code" : "TAB"
      },
      "net" : {
        "value" : 90.00,
        "currency" : "USD"
      },
      "detail" : [
        {
          "sequence" : 1,
          "productOrService" : {
            "coding" : [
              {
                "system" : "http://hl7.org/fhir/ex-pharmaservice",
                "code" : "drugcost"
              }
            ]
          },
          "net" : {
            "value" : 45.00,
            "currency" : "USD"
          }
        },
        {
          "sequence" : 2,
          "productOrService" : {
            "coding" : [
              {
                "system" : "http://hl7.org/fhir/ex-pharmaservice",
                "code" : "markup"
              }
            ]
          },
          "net" : {
            "value" : 9.00,
            "currency" : "USD"
          }
        },
        {
          "sequence" : 3,
          "productOrService" : {
            "coding" : [
              {
                "system" : "http://hl7.org/fhir/ex-pharmaservice",
                "code" : "dispensefee"
              }
            ]
          },
          "net" : {
            "value" : 36.00,
            "currency" : "USD"
          }
        }
      ]
    }
  ],
  "total" : {
    "value" : 90.00,
    "currency" : "USD"
  }
}

Claim "760150" Version "1"

Tags: (no tags)  +

This Resource , XML or JSON representation, or the full version history.. provenance for this resource
Updated: by

A human-readable rendering of the Pharmacy Claim

{
  "resourceType" : "Claim",
  "id" : "760150",
  "meta" : {
    "versionId" : "1",
    "lastUpdated" : "2018-12-14T02:01:33.911Z"
  },
  "text" : {
    "status" : "generated",
    "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\">A human-readable rendering of the Pharmacy Claim</div>"
  },
  "identifier" : [
    {
      "system" : "http://happypharma.com/claim",
      "value" : "7612345"
    }
  ],
  "status" : "active",
  "type" : {
    "coding" : [
      {
        "system" : "http://terminology.hl7.org/CodeSystem/claim-type",
        "code" : "pharmacy"
      }
    ]
  },
  "use" : "claim",
  "patient" : {
    "reference" : "Patient/1"
  },
  "created" : "2014-08-16",
  "insurer" : {
    "reference" : "Organization/2"
  },
  "provider" : {
    "reference" : "Organization/1"
  },
  "priority" : {
    "coding" : [
      {
        "code" : "stat"
      }
    ]
  },
  "payee" : {
    "type" : {
      "coding" : [
        {
          "code" : "provider"
        }
      ]
    }
  },
  "careTeam" : [
    {
      "sequence" : 1,
      "provider" : {
        "reference" : "Practitioner/example"
      }
    }
  ],
  "diagnosis" : [
    {
      "sequence" : 1,
      "diagnosisCodeableConcept" : {
        "coding" : [
          {
            "code" : "654456"
          }
        ]
      }
    }
  ],
  "insurance" : [
    {
      "sequence" : 1,
      "focal" : true,
      "coverage" : {
        "reference" : "Coverage/9876B1"
      }
    }
  ],
  "item" : [
    {
      "sequence" : 1,
      "careTeamSequence" : [
        "1"
      ],
      "productOrService" : {
        "coding" : [
          {
            "system" : "http://hl7.org/fhir/ex-pharmaservice",
            "code" : "smokecess"
          }
        ]
      },
      "servicedDate" : "2014-08-16",
      "unitPrice" : {
        "value" : 60.00,
        "currency" : "USD"
      },
      "net" : {
        "value" : 60.00,
        "currency" : "USD"
      }
    }
  ]
}

Claim "660152" Version "1"

Tags: (no tags)  +

This Resource , XML or JSON representation, or the full version history.. provenance for this resource
Updated: by

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"
          }
        }
      ]
    }
  ]
}

Claim "660151" Version "1"

Tags: (no tags)  +

This Resource , XML or JSON representation, or the full version history.. provenance for this resource
Updated: by

A human-readable rendering of the Vision Claim for Glasses

{
  "resourceType" : "Claim",
  "id" : "660151",
  "meta" : {
    "versionId" : "1",
    "lastUpdated" : "2018-12-14T02:01:33.848Z"
  },
  "text" : {
    "status" : "generated",
    "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\">A human-readable rendering of the Vision Claim for Glasses</div>"
  },
  "identifier" : [
    {
      "system" : "http://happysight.com/claim",
      "value" : "6612346"
    }
  ],
  "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" : true,
      "coverage" : {
        "reference" : "Coverage/9876B1"
      }
    }
  ],
  "item" : [
    {
      "sequence" : 1,
      "careTeamSequence" : [
        "1"
      ],
      "productOrService" : {
        "coding" : [
          {
            "system" : "http://example.org/fhir/CodeSystem/ex-visionservice",
            "code" : "glasses"
          }
        ]
      },
      "servicedDate" : "2014-08-16",
      "unitPrice" : {
        "value" : 214.00,
        "currency" : "USD"
      },
      "net" : {
        "value" : 214.00,
        "currency" : "USD"
      },
      "detail" : [
        {
          "sequence" : 1,
          "productOrService" : {
            "coding" : [
              {
                "system" : "http://example.org/fhir/CodeSystem/ex-visionservice",
                "code" : "frame"
              }
            ]
          },
          "unitPrice" : {
            "value" : 100.00,
            "currency" : "USD"
          },
          "net" : {
            "value" : 100.00,
            "currency" : "USD"
          }
        },
        {
          "sequence" : 2,
          "productOrService" : {
            "coding" : [
              {
                "system" : "http://example.org/fhir/CodeSystem/ex-visionservice",
                "code" : "lens"
              }
            ]
          },
          "quantity" : {
            "value" : 2
          },
          "unitPrice" : {
            "value" : 50.00,
            "currency" : "USD"
          },
          "net" : {
            "value" : 100.00,
            "currency" : "USD"
          }
        },
        {
          "sequence" : 3,
          "productOrService" : {
            "coding" : [
              {
                "system" : "http://example.org/fhir/CodeSystem/ex-visionservice",
                "code" : "fst"
              }
            ]
          },
          "unitPrice" : {
            "value" : 200.00,
            "currency" : "USD"
          },
          "factor" : 0.07,
          "net" : {
            "value" : 14.00,
            "currency" : "USD"
          }
        }
      ]
    }
  ]
}

Claim "660150" Version "1"

Tags: (no tags)  +

This Resource , XML or JSON representation, or the full version history.. provenance for this resource
Updated: by

A human-readable rendering of the Vision Claim

{
  "resourceType" : "Claim",
  "id" : "660150",
  "meta" : {
    "versionId" : "1",
    "lastUpdated" : "2018-12-14T02:01:33.801Z"
  },
  "text" : {
    "status" : "generated",
    "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\">A human-readable rendering of the Vision Claim</div>"
  },
  "identifier" : [
    {
      "system" : "http://happysight.com/claim",
      "value" : "6612345"
    }
  ],
  "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"
      }
    ]
  },
  "payee" : {
    "type" : {
      "coding" : [
        {
          "code" : "provider"
        }
      ]
    }
  },
  "careTeam" : [
    {
      "sequence" : 1,
      "provider" : {
        "reference" : "Practitioner/example"
      }
    }
  ],
  "diagnosis" : [
    {
      "sequence" : 1,
      "diagnosisCodeableConcept" : {
        "coding" : [
          {
            "code" : "654321"
          }
        ]
      }
    }
  ],
  "insurance" : [
    {
      "sequence" : 1,
      "focal" : true,
      "coverage" : {
        "reference" : "Coverage/9876B1"
      }
    }
  ],
  "item" : [
    {
      "sequence" : 1,
      "careTeamSequence" : [
        "1"
      ],
      "productOrService" : {
        "coding" : [
          {
            "system" : "http://example.org/fhir/CodeSystem/ex-visionservice",
            "code" : "exam"
          }
        ]
      },
      "servicedDate" : "2014-08-16",
      "unitPrice" : {
        "value" : 80.00,
        "currency" : "USD"
      },
      "net" : {
        "value" : 80.00,
        "currency" : "USD"
      }
    }
  ]
}

Claim "100156" Version "1"

Tags: (no tags)  +

This Resource , XML or JSON representation, or the full version history.. provenance for this resource
Updated: by

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"
  }
}

Claim "100155" Version "1"

Tags: (no tags)  +

This Resource , XML or JSON representation, or the full version history.. provenance for this resource
Updated: by

This example assumes a national health care scheme where patients, providers and organizations have known business identifiers.

{
  "resourceType" : "Claim",
  "id" : "100155",
  "meta" : {
    "versionId" : "1",
    "lastUpdated" : "2018-12-14T02:01:33.723Z"
  },
  "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>"
  },
  "contained" : [
    {
      "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"
        }
      ]
    }
  ],
  "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" : {
    "identifier" : {
      "system" : "http://www.jurisdiction.com/insurers",
      "value" : "123456"
    }
  },
  "provider" : {
    "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" : {
        "reference" : "http://www.jurisdiction.com/nationalplan/123AB345"
      }
    }
  ],
  "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"
      }
    }
  ]
}

Claim "100154" Version "1"

Tags: (no tags)  +

This Resource , XML or JSON representation, or the full version history.. provenance for this resource
Updated: by

This example assumes a national health care scheme where patients, providers and organizations have known business identifiers.

{
  "resourceType" : "Claim",
  "id" : "100154",
  "meta" : {
    "versionId" : "1",
    "lastUpdated" : "2018-12-14T02:01:33.692Z"
  },
  "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://terminology.hl7.org/CodeSystem/claim-type",
        "code" : "oral"
      }
    ]
  },
  "use" : "claim",
  "patient" : {
    "identifier" : {
      "system" : "http://www.jurisdiction.com/nationalId",
      "value" : "123AB345"
    }
  },
  "created" : "2014-08-16",
  "insurer" : {
    "identifier" : {
      "system" : "http://www.jurisdiction.com/insurers",
      "value" : "123456"
    }
  },
  "provider" : {
    "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,
      "careTeamSequence" : [
        "1"
      ],
      "productOrService" : {
        "coding" : [
          {
            "code" : "1200"
          }
        ]
      },
      "servicedDate" : "2014-08-16",
      "unitPrice" : {
        "value" : 135.57,
        "currency" : "USD"
      },
      "net" : {
        "value" : 135.57,
        "currency" : "USD"
      }
    }
  ]
}

Claim "100153" Version "1"

Tags: (no tags)  +

This Resource , XML or JSON representation, or the full version history.. provenance for this resource
Updated: by

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"
          }
        }
      ]
    }
  ]
}

Claim "100152" Version "1"

Tags: (no tags)  +

This Resource , XML or JSON representation, or the full version history.. provenance for this resource
Updated: by

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"
      }
    }
  ]
}

Claim "100151" Version "1"

Tags: (no tags)  +

This Resource , XML or JSON representation, or the full version history.. provenance for this resource
Updated: by

A human-readable rendering of the Oral Health Claim

{
  "resourceType" : "Claim",
  "id" : "100151",
  "meta" : {
    "versionId" : "1",
    "lastUpdated" : "2018-12-14T02:01:33.567Z"
  },
  "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" : "12346"
    }
  ],
  "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"
      }
    ]
  },
  "payee" : {
    "type" : {
      "coding" : [
        {
          "code" : "provider"
        }
      ]
    }
  },
  "careTeam" : [
    {
      "sequence" : 1,
      "provider" : {
        "reference" : "Practitioner/example"
      }
    }
  ],
  "supportingInfo" : [
    {
      "sequence" : 1,
      "category" : {
        "coding" : [
          {
            "system" : "http://terminology.hl7.org/CodeSystem/claiminformationcategory",
            "code" : "missingtooth"
          }
        ]
      },
      "code" : {
        "coding" : [
          {
            "system" : "http://terminology.hl7.org/CodeSystem/ex-tooth",
            "code" : "15"
          }
        ]
      },
      "timingDate" : "2012-04-07",
      "reason" : {
        "coding" : [
          {
            "system" : "http://terminology.hl7.org/CodeSystem/missingtoothreason",
            "code" : "e"
          }
        ]
      }
    },
    {
      "sequence" : 2,
      "category" : {
        "coding" : [
          {
            "system" : "http://terminology.hl7.org/CodeSystem/claiminformationcategory",
            "code" : "exception"
          }
        ]
      },
      "code" : {
        "coding" : [
          {
            "system" : "http://terminology.hl7.org/CodeSystem/claim-exception",
            "code" : "student"
          }
        ]
      },
      "valueString" : "Happy Valley Community College"
    }
  ],
  "diagnosis" : [
    {
      "sequence" : 1,
      "diagnosisCodeableConcept" : {
        "coding" : [
          {
            "code" : "123456"
          }
        ]
      }
    }
  ],
  "insurance" : [
    {
      "sequence" : 1,
      "focal" : true,
      "coverage" : {
        "reference" : "Coverage/9876B1"
      }
    }
  ],
  "item" : [
    {
      "sequence" : 1,
      "careTeamSequence" : [
        "1"
      ],
      "productOrService" : {
        "coding" : [
          {
            "system" : "http://example.org/fhir/oralservicecodes",
            "code" : "1200"
          }
        ]
      },
      "servicedDate" : "2014-08-16",
      "unitPrice" : {
        "value" : 135.57,
        "currency" : "USD"
      },
      "net" : {
        "value" : 135.57,
        "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" : 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"
          }
        }
      ]
    }
  ]
}

Claim "100150" Version "1"

Tags: (no tags)  +

This Resource , XML or JSON representation, or the full version history.. provenance for this resource
Updated: by

A human-readable rendering of the Oral Health Claim

{
  "resourceType" : "Claim",
  "id" : "100150",
  "meta" : {
    "versionId" : "1",
    "lastUpdated" : "2018-12-14T02:01:33.520Z"
  },
  "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" : "12345"
    }
  ],
  "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"
      }
    ]
  },
  "payee" : {
    "type" : {
      "coding" : [
        {
          "code" : "provider"
        }
      ]
    }
  },
  "careTeam" : [
    {
      "sequence" : 1,
      "provider" : {
        "reference" : "Practitioner/example"
      }
    }
  ],
  "diagnosis" : [
    {
      "sequence" : 1,
      "diagnosisCodeableConcept" : {
        "coding" : [
          {
            "code" : "123456"
          }
        ]
      }
    }
  ],
  "insurance" : [
    {
      "sequence" : 1,
      "focal" : true,
      "identifier" : {
        "system" : "http://happyvalley.com/claim",
        "value" : "12345"
      },
      "coverage" : {
        "reference" : "Coverage/9876B1"
      }
    }
  ],
  "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"
      }
    }
  ]
}