This is the Continuous Integration Build of FHIR (will be incorrect/inconsistent at times).
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Financial Management Work Group | Maturity Level: N/A | Standards Status: Informative | Compartments: Patient, Practitioner |
Raw XML (canonical form + also see XML Format Specification)
Unsolicited Pre-Authorization for social Dental Services (id = "UR3503")
<?xml version="1.0" encoding="UTF-8"?> <ClaimResponse xmlns="http://hl7.org/fhir"> <id value="UR3503"/> <text> <status value="generated"/> <div xmlns="http://www.w3.org/1999/xhtml">A sample unsolicited pre-authorization response which authorizes basic dental services to be performed for a patient.</div> </text> <identifier> <system value="http://www.SocialBenefitsInc.com/fhir/ClaimResponse"/> <value value="UR3503"/> </identifier> <status value="active"/> <type> <coding> <system value="http://terminology.hl7.org/CodeSystem/claim-type"/> <code value="oral"/> </coding> </type> <use value="preauthorization"/> <!-- this is unsolicited therefore no reference to the preauthorization request exists --> <patient> <reference value="Patient/1"/> </patient> <created value="2014-08-16"/> <insurer> <!-- Social Benefits Inc. --> <identifier> <system value="http://www.jurisdiction.org/insurers"/> <value value="444123"/> </identifier> </insurer> <requestor> <reference value="Organization/1"/> </requestor> <outcome value="complete"/> <disposition value="The enclosed services are authorized for your provision within 30 days of this notice."/> <preAuthRef value="18SS12345"/> <payeeType> <!-- advise that assignment of benefit is allowed --> <coding> <system value="http://terminology.hl7.org/CodeSystem/payeetype"/> <code value="provider"/> </coding> </payeeType> <!-- Authorization details --> <!-- Authorization to receive an exam and an Xray panel --> <addItem> <!-- Exam --> <itemSequence value="1"/> <productOrService> <coding> <system value="http://example.org/fhir/oralservicecodes"/> <code value="1101"/> </coding> </productOrService> <modifier> <coding> <system value="http://example.org/fhir/modifiers"/> <code value="x"/> <display value="None"/> </coding> </modifier> <net> <value value="250.00"/> <!-- net set to same value as the eligible amount. Providers will only be reimbursed to the net/eligible amount less the co-pay. --> <currency value="USD"/> </net> <noteNumber value="101"/> <adjudication> <category> <coding> <code value="eligible"/> </coding> </category> <amount> <value value="250.00"/> <currency value="USD"/> </amount> </adjudication> <adjudication> <category> <coding> <code value="copay"/> </coding> </category> <amount> <value value="10.00"/> <currency value="USD"/> </amount> </adjudication> <adjudication> <category> <coding> <code value="eligpercent"/> </coding> </category> <quantity> <value value="100.00"/> </quantity> </adjudication> <adjudication> <category> <coding> <code value="benefit"/> </coding> </category> <amount> <value value="240.00"/> <!-- insurer will pay up to this amount. --> <currency value="USD"/> </amount> </adjudication> </addItem> <addItem> <!-- Xray Panel --> <itemSequence value="1"/> <productOrService> <coding> <system value="http://example.org/fhir/oralservicecodes"/> <code value="2101"/> <display value="Radiograph, series (12)"/> </coding> </productOrService> <net> <value value="800.00"/> <currency value="USD"/> </net> <adjudication> <category> <coding> <code value="eligible"/> </coding> </category> <amount> <value value="800.00"/> <currency value="USD"/> </amount> </adjudication> <adjudication> <category> <coding> <code value="eligpercent"/> </coding> </category> <quantity> <value value="100.00"/> </quantity> </adjudication> <adjudication> <category> <coding> <code value="benefit"/> </coding> </category> <amount> <value value="800.00"/> <currency value="USD"/> </amount> </adjudication> </addItem> <total> <category> <coding> <code value="submitted"/> </coding> </category> <amount> <value value="1050.00"/> <currency value="USD"/> </amount> </total> <total> <category> <coding> <code value="benefit"/> </coding> </category> <amount> <value value="1040.00"/> <currency value="USD"/> </amount> </total> <processNote> <number value="101"/> <type> <coding> <system value="http://hl7.org/fhir/note-type"/> <code value="print"/> </coding> </type> <text value="Please submit a Pre-Authorization request if a more extensive examination or urgent services are required."/> <language> <coding> <system value="urn:ietf:bcp:47"/> <code value="en-CA"/> </coding> </language> </processNote> <insurance> <sequence value="1"/> <focal value="true"/> <coverage> <reference value="Coverage/9876B1"/> </coverage> </insurance> </ClaimResponse>
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 Wed, Nov 27, 2024 19:50+0000.
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