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Financial Management Work Group | Maturity Level: N/A | Standards Status: Informative | Compartments: Patient, Practitioner |
Raw Turtle (+ also see Turtle/RDF Format Specification)
A ClaimResponse demonstrating Payor service code substitutions
@prefix fhir: <http://hl7.org/fhir/> . @prefix owl: <http://www.w3.org/2002/07/owl#> . @prefix rdfs: <http://www.w3.org/2000/01/rdf-schema#> . @prefix xsd: <http://www.w3.org/2001/XMLSchema#> . # - resource ------------------------------------------------------------------- [a fhir:ClaimResponse ; fhir:nodeRole fhir:treeRoot ; fhir:id [ fhir:v "R3503"] ; # fhir:text [ fhir:status [ fhir:v "generated" ] ; fhir:div "<div xmlns=\"http://www.w3.org/1999/xhtml\">A human-readable rendering of the ClaimResponse to Claim Oral Average with additional items</div>" ] ; # fhir:identifier ( [ fhir:system [ fhir:v "http://www.BenefitsInc.com/fhir/remittance"^^xsd:anyURI ] ; fhir:value [ fhir:v "R3503" ] ] ) ; # fhir:status [ fhir:v "active"] ; # fhir:type [ fhir:coding ( [ fhir:system [ fhir:v "http://terminology.hl7.org/CodeSystem/claim-type"^^xsd:anyURI ] ; fhir:code [ fhir:v "oral" ] ] ) ] ; # fhir:use [ fhir:v "claim"] ; # fhir:patient [ fhir:reference [ fhir:v "Patient/1" ] ] ; # fhir:created [ fhir:v "2014-08-16"^^xsd:date] ; # fhir:insurer [ fhir:identifier [ fhir:system [ fhir:v "http://www.jurisdiction.org/insurers"^^xsd:anyURI ] ; fhir:value [ fhir:v "555123" ] ] ] ; # fhir:requestor [ fhir:reference [ fhir:v "Organization/1" ] ] ; # fhir:request [ fhir:identifier [ fhir:system [ fhir:v "http://happyvalley.com/claim"^^xsd:anyURI ] ; fhir:value [ fhir:v "12346" ] ] ] ; # fhir:outcome [ fhir:v "complete"] ; # fhir:disposition [ fhir:v "Claim settled as per contract."] ; # fhir:payeeType [ fhir:coding ( [ fhir:system [ fhir:v "http://terminology.hl7.org/CodeSystem/payeetype"^^xsd:anyURI ] ; fhir:code [ fhir:v "provider" ] ] ) ] ; # fhir:item ( [ fhir:itemSequence [ fhir:v "1"^^xsd:positiveInteger ] ; # Pays for a claim package code with two actual codes with adjudication details fhir:adjudication ( [ fhir:category [ fhir:coding ( [ fhir:code [ fhir:v "eligible" ] ] ) ] ; fhir:amount [ fhir:value [ fhir:v "0.00"^^xsd:decimal ] ; fhir:currency [ fhir:v "USD" ] ] ] [ fhir:category [ fhir:coding ( [ fhir:code [ fhir:v "benefit" ] ] ) ] ; fhir:amount [ fhir:value [ fhir:v "0.00"^^xsd:decimal ] ; fhir:currency [ fhir:v "USD" ] ] ] ) ] [ fhir:itemSequence [ fhir:v "2"^^xsd:positiveInteger ] ; fhir:adjudication ( [ fhir:category [ fhir:coding ( [ fhir:code [ fhir:v "eligible" ] ] ) ] ; fhir:amount [ fhir:value [ fhir:v "105.00"^^xsd:decimal ] ; fhir:currency [ fhir:v "USD" ] ] ] [ fhir:category [ fhir:coding ( [ fhir:code [ fhir:v "eligpercent" ] ] ) ] ; fhir:quantity [ fhir:value [ fhir:v "80.00"^^xsd:decimal ] ] ] [ fhir:category [ fhir:coding ( [ fhir:code [ fhir:v "benefit" ] ] ) ] ; fhir:amount [ fhir:value [ fhir:v "84.00"^^xsd:decimal ] ; fhir:currency [ fhir:v "USD" ] ] ] ) ] [ fhir:itemSequence [ fhir:v "3"^^xsd:positiveInteger ] ; fhir:adjudication ( [ fhir:category [ fhir:coding ( [ fhir:code [ fhir:v "eligible" ] ] ) ] ; fhir:amount [ fhir:value [ fhir:v "750.00"^^xsd:decimal ] ; fhir:currency [ fhir:v "USD" ] ] ] [ fhir:category [ fhir:coding ( [ fhir:code [ fhir:v "eligpercent" ] ] ) ] ; fhir:quantity [ fhir:value [ fhir:v "80.00"^^xsd:decimal ] ] ] [ fhir:category [ fhir:coding ( [ fhir:code [ fhir:v "benefit" ] ] ) ] ; fhir:amount [ fhir:value [ fhir:v "600.00"^^xsd:decimal ] ; fhir:currency [ fhir:v "USD" ] ] ] ) ; fhir:detail ( [ fhir:detailSequence [ fhir:v "1"^^xsd:positiveInteger ] ; fhir:adjudication ( [ fhir:category [ fhir:coding ( [ fhir:code [ fhir:v "eligible" ] ] ) ] ; fhir:amount [ fhir:value [ fhir:v "750.00"^^xsd:decimal ] ; fhir:currency [ fhir:v "USD" ] ] ] [ fhir:category [ fhir:coding ( [ fhir:code [ fhir:v "eligpercent" ] ] ) ] ; fhir:quantity [ fhir:value [ fhir:v "80.00"^^xsd:decimal ] ] ] [ fhir:category [ fhir:coding ( [ fhir:code [ fhir:v "benefit" ] ] ) ] ; fhir:amount [ fhir:value [ fhir:v "600.00"^^xsd:decimal ] ; fhir:currency [ fhir:v "USD" ] ] ] ) ] [ fhir:detailSequence [ fhir:v "2"^^xsd:positiveInteger ] ; # See the addItem.detail below fhir:adjudication ( [ fhir:category [ fhir:coding ( [ fhir:code [ fhir:v "eligible" ] ] ) ] ; fhir:amount [ fhir:value [ fhir:v "0.00"^^xsd:decimal ] ; fhir:currency [ fhir:v "USD" ] ] ] [ fhir:category [ fhir:coding ( [ fhir:code [ fhir:v "benefit" ] ] ) ] ; fhir:amount [ fhir:value [ fhir:v "0.00"^^xsd:decimal ] ; fhir:currency [ fhir:v "USD" ] ] ] ) ] ) ] ) ; # Adjudication details fhir:addItem ( [ fhir:itemSequence ( [ fhir:v "1"^^xsd:positiveInteger ] ) ; fhir:productOrService [ fhir:coding ( [ fhir:system [ fhir:v "http://example.org/fhir/oralservicecodes"^^xsd:anyURI ] ; fhir:code [ fhir:v "1101" ] ] ) ] ; fhir:modifier ( [ fhir:coding ( [ fhir:system [ fhir:v "http://example.org/fhir/modifiers"^^xsd:anyURI ] ; fhir:code [ fhir:v "x" ] ; fhir:display [ fhir:v "None" ] ] ) ] ) ; fhir:net [ fhir:value [ fhir:v "135.57"^^xsd:decimal ] ; fhir:currency [ fhir:v "USD" ] ] ; fhir:noteNumber ( [ fhir:v "101"^^xsd:positiveInteger ] ) ; fhir:adjudication ( [ fhir:category [ fhir:coding ( [ fhir:code [ fhir:v "eligible" ] ] ) ] ; fhir:amount [ fhir:value [ fhir:v "100.00"^^xsd:decimal ] ; fhir:currency [ fhir:v "USD" ] ] ] [ fhir:category [ fhir:coding ( [ fhir:code [ fhir:v "copay" ] ] ) ] ; fhir:amount [ fhir:value [ fhir:v "10.00"^^xsd:decimal ] ; fhir:currency [ fhir:v "USD" ] ] ] [ fhir:category [ fhir:coding ( [ fhir:code [ fhir:v "eligpercent" ] ] ) ] ; fhir:quantity [ fhir:value [ fhir:v "80.00"^^xsd:decimal ] ] ] [ fhir:category [ fhir:coding ( [ fhir:code [ fhir:v "benefit" ] ] ) ] ; fhir:reason [ fhir:coding ( [ fhir:system [ fhir:v "http://terminology.hl7.org/CodeSystem/adjudication-reason"^^xsd:anyURI ] ; fhir:code [ fhir:v "ar002" ] ; fhir:display [ fhir:v "Plan Limit Reached" ] ] ) # should have paid 100.47 ] ; fhir:amount [ fhir:value [ fhir:v "72.00"^^xsd:decimal ] ; fhir:currency [ fhir:v "USD" ] ] ] ) ] [ fhir:itemSequence ( [ fhir:v "1"^^xsd:positiveInteger ] ) ; fhir:productOrService [ fhir:coding ( [ fhir:system [ fhir:v "http://example.org/fhir/oralservicecodes"^^xsd:anyURI ] ; fhir:code [ fhir:v "2141" ] ; fhir:display [ fhir:v "Radiograph, bytewing" ] ] ) ] ; fhir:net [ fhir:value [ fhir:v "35.57"^^xsd:decimal ] ; fhir:currency [ fhir:v "USD" ] ] ; fhir:adjudication ( [ fhir:category [ fhir:coding ( [ fhir:code [ fhir:v "eligible" ] ] ) ] ; fhir:amount [ fhir:value [ fhir:v "35.57"^^xsd:decimal ] ; fhir:currency [ fhir:v "USD" ] ] ] [ fhir:category [ fhir:coding ( [ fhir:code [ fhir:v "eligpercent" ] ] ) ] ; fhir:quantity [ fhir:value [ fhir:v "80.00"^^xsd:decimal ] ] ] [ fhir:category [ fhir:coding ( [ fhir:code [ fhir:v "benefit" ] ] ) ] ; fhir:amount [ fhir:value [ fhir:v "28.47"^^xsd:decimal ] ; fhir:currency [ fhir:v "USD" ] ] ] ) ] [ fhir:itemSequence ( [ fhir:v "3"^^xsd:positiveInteger ] ) ; fhir:detailSequence ( [ fhir:v "2"^^xsd:positiveInteger ] ) ; fhir:productOrService [ fhir:coding ( [ fhir:system [ fhir:v "http://example.org/fhir/oralservicecodes"^^xsd:anyURI ] ; fhir:code [ fhir:v "expense" ] ] ) ] ; fhir:modifier ( [ fhir:coding ( [ fhir:system [ fhir:v "http://example.org/fhir/modifiers"^^xsd:anyURI ] ; fhir:code [ fhir:v "x" ] ; fhir:display [ fhir:v "None" ] ] ) ] ) ; fhir:net [ fhir:value [ fhir:v "350.00"^^xsd:decimal ] ; fhir:currency [ fhir:v "USD" ] ] ; fhir:noteNumber ( [ fhir:v "101"^^xsd:positiveInteger ] ) ; fhir:adjudication ( [ fhir:category [ fhir:coding ( [ fhir:code [ fhir:v "eligible" ] ] ) ] ; fhir:amount [ fhir:value [ fhir:v "350.00"^^xsd:decimal ] ; fhir:currency [ fhir:v "USD" ] ] ] [ fhir:category [ fhir:coding ( [ fhir:code [ fhir:v "eligpercent" ] ] ) ] ; fhir:quantity [ fhir:value [ fhir:v "80.00"^^xsd:decimal ] ] ] [ fhir:category [ fhir:coding ( [ fhir:code [ fhir:v "benefit" ] ] ) ] ; fhir:amount [ fhir:value [ fhir:v "270.00"^^xsd:decimal ] ; fhir:currency [ fhir:v "USD" ] ] ] ) ] ) ; # Pays for a claim package code (1200) with two actual codes (1101, 2141) with adjudication details fhir:total ( [ fhir:category [ fhir:coding ( [ fhir:code [ fhir:v "submitted" ] ] ) ] ; fhir:amount [ fhir:value [ fhir:v "1340.57"^^xsd:decimal ] ; fhir:currency [ fhir:v "USD" ] ] ] [ fhir:category [ fhir:coding ( [ fhir:code [ fhir:v "benefit" ] ] ) ] ; fhir:amount [ fhir:value [ fhir:v "1054.47"^^xsd:decimal ] ; fhir:currency [ fhir:v "USD" ] ] ] ) ; # fhir:payment [ fhir:type [ fhir:coding ( [ fhir:system [ fhir:v "http://terminology.hl7.org/CodeSystem/ex-paymenttype"^^xsd:anyURI ] ; fhir:code [ fhir:v "complete" ] ] ) ] ; fhir:date [ fhir:v "2014-08-31"^^xsd:date ] ; fhir:amount [ fhir:value [ fhir:v "100.47"^^xsd:decimal ] ; fhir:currency [ fhir:v "USD" ] ] ; fhir:identifier [ fhir:system [ fhir:v "http://www.BenefitsInc.com/fhir/paymentidentifier"^^xsd:anyURI ] ; fhir:value [ fhir:v "201408-2-15507" ] ] ] ; # Payment details fhir:processNote ( [ fhir:number [ fhir:v "101"^^xsd:positiveInteger ] ; fhir:type [ fhir:coding ( [ fhir:system [ fhir:v "http://hl7.org/fhir/note-type"^^xsd:anyURI ] ; fhir:code [ fhir:v "print" ] ] ) ] ; fhir:text [ fhir:v "Package codes are not permitted. Codes replaced by Insurer." ] ; fhir:language [ fhir:coding ( [ fhir:system [ fhir:v "urn:ietf:bcp:47"^^xsd:anyURI ] ; fhir:code [ fhir:v "en-CA" ] ] ) ] ] )] . # # -------------------------------------------------------------------------------------
Usage note: every effort has been made to ensure that the examples are correct and useful, but they are not a normative part of the specification.
FHIR ®© HL7.org 2011+. FHIR R6 hl7.fhir.core#6.0.0-ballot2 generated on Sat, Nov 9, 2024 19:13+0000.
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