Claim-example-oral-orthoplan.json

PreAuthorization with Orthodontic Treatment Plan

{
  "resourceType": "Claim",
  "id": "100153",
  "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"
          }
        }
      ]
    }
  ]
}