{ "resourceType" : "Claim", "id" : "Claim-preauthorization-example-01", "meta" : { "profile" : ["https://nrces.in/ndhm/fhir/r4/StructureDefinition/Claim"] }, "text" : { "status" : "generated", "div" : "

Generated Narrative: Claim Claim-preauthorization-example-01

identifier: 7612345

status: Active

type: Inpatient care management (procedure)

subType: Emergency Claim

use: Preauthorization

patient: ABC Male, DoB: 1981-01-12 ( Medical record number: 22-7225-4829-5255)

billablePeriod: 2025-03-07 11:01:00+0500 --> 2025-04-07 11:01:00+0500

created: 2025-03-08 11:01:00+0500

insurer: Organization XYZ Insurance Co. Ltd.

provider: Organization XYZ Hospital Co. Ltd.

priority: Normal

CareTeams

-SequenceProviderRoleQualification
*1Practitioner Dr. DEFHealthcare professional (occupation)Clinical specialty (qualifier value)

Diagnoses

-SequenceDiagnosis[x]Type
*1Cardiac arrest, unspecifiedFinal diagnosis (discharge) (contextual qualifier) (qualifier value)

procedure

sequence: 1

procedure: Angiography

procedure

sequence: 2

procedure: Angioplasty of blood vessel

Insurances

-SequenceFocalCoverage
*1trueCoverage: identifier = https://xyzinsurance.in/policynumber/#235037120; status = active; type = PAY; subscriberId = ABC123456BI007; relationship = Self; period = (?) --> 2026-03-17

item

sequence: 1

careTeamSequence: 1

productOrService: Angiography

UnitPrices

-ValueCurrency
*10000Indian rupee

Nets

-ValueCurrency
*10000Indian rupee

item

sequence: 2

careTeamSequence: 1

productOrService: Angioplasty of blood vessel

UnitPrices

-ValueCurrency
*40000Indian rupee

Nets

-ValueCurrency
*40000Indian rupee

item

sequence: 3

careTeamSequence: 1

productOrService: Intensive care unit

UnitPrices

-ValueCurrency
*2000Indian rupee

Nets

-ValueCurrency
*20000Indian rupee

Totals

-ValueCurrency
*70000Indian rupee
" }, "identifier" : [{ "value" : "7612345" }], "status" : "active", "type" : { "coding" : [{ "system" : "http://snomed.info/sct", "code" : "737481003", "display" : "Inpatient care management (procedure)" }] }, "subType" : { "coding" : [{ "system" : "http://terminology.hl7.org/CodeSystem/ex-claimsubtype", "code" : "emergency" }] }, "use" : "preauthorization", "patient" : { "reference" : "Patient/example-01" }, "billablePeriod" : { "start" : "2025-03-07T11:01:00+05:00", "end" : "2025-04-07T11:01:00+05:00" }, "created" : "2025-03-08T11:01:00+05:00", "insurer" : { "reference" : "Organization/example-02" }, "provider" : { "reference" : "Organization/example-03" }, "priority" : { "coding" : [{ "system" : "http://terminology.hl7.org/CodeSystem/processpriority", "code" : "normal" }] }, "careTeam" : [{ "sequence" : 1, "provider" : { "reference" : "Practitioner/example-01" }, "role" : { "coding" : [{ "system" : "http://snomed.info/sct", "code" : "223366009", "display" : "Healthcare professional (occupation)" }] }, "qualification" : { "coding" : [{ "system" : "http://snomed.info/sct", "code" : "394658006", "display" : "Clinical specialty (qualifier value)" }] } }], "diagnosis" : [{ "sequence" : 1, "diagnosisCodeableConcept" : { "coding" : [{ "system" : "http://hl7.org/fhir/sid/icd-10", "code" : "I46.9", "display" : "Cardiac arrest, unspecified" }] }, "type" : [{ "coding" : [{ "system" : "http://snomed.info/sct", "code" : "89100005", "display" : "Final diagnosis (discharge) (contextual qualifier) (qualifier value)" }] }] }], "procedure" : [{ "sequence" : 1, "procedureCodeableConcept" : { "coding" : [{ "system" : "http://snomed.info/sct", "code" : "77343006", "display" : "Angiography" }] } }, { "sequence" : 2, "procedureCodeableConcept" : { "coding" : [{ "system" : "http://snomed.info/sct", "code" : "418285008", "display" : "Angioplasty of blood vessel" }] } }], "insurance" : [{ "sequence" : 1, "focal" : true, "coverage" : { "reference" : "Coverage/example-01" } }], "item" : [{ "sequence" : 1, "careTeamSequence" : [1], "productOrService" : { "coding" : [{ "system" : "http://snomed.info/sct", "code" : "77343006", "display" : "Angiography" }] }, "unitPrice" : { "value" : 10000, "currency" : "INR" }, "net" : { "value" : 10000, "currency" : "INR" } }, { "sequence" : 2, "careTeamSequence" : [1], "productOrService" : { "coding" : [{ "system" : "http://snomed.info/sct", "code" : "418285008", "display" : "Angioplasty of blood vessel" }] }, "unitPrice" : { "value" : 40000, "currency" : "INR" }, "net" : { "value" : 40000, "currency" : "INR" } }, { "sequence" : 3, "careTeamSequence" : [1], "productOrService" : { "coding" : [{ "system" : "http://snomed.info/sct", "code" : "309904001", "display" : "Intensive care unit" }] }, "unitPrice" : { "value" : 2000, "currency" : "INR" }, "net" : { "value" : 20000, "currency" : "INR" } }], "total" : { "value" : 70000, "currency" : "INR" } }