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Claim-example-vision-glasses-3tier.json

Financial Management Work GroupMaturity Level: N/ABallot Status: InformativeCompartments: Encounter, Patient, Practitioner, RelatedPerson

Raw JSON (canonical form + also see JSON Format Specification)

Glasses Claim, 3 Tier, Secondary Coverage

{
  "resourceType": "Claim",
  "id": "660152",
  "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": "ClaimResponse",
      "id": "claimresponse-1",
      "identifier": [
        {
          "system": "http://thebenefircompany.com/claimresponse",
          "value": "CR6532875367"
        }
      ],
      "use": "claim"
    },
    {
      "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-1"
      }
    },
    {
      "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"
          }
        ]
      },
      "billcode": {
        "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"
              }
            ]
          },
          "billcode": {
            "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"
              }
            ]
          },
          "billcode": {
            "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"
                  }
                ]
              },
              "billcode": {
                "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"
                  }
                ]
              },
              "billcode": {
                "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"
                  }
                ]
              },
              "billcode": {
                "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"
              }
            ]
          },
          "billcode": {
            "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"
          }
        }
      ]
    }
  ]
}

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.