devsofttech_hms_ci4/ABDM_FHIR/examples.json/Claim-Claim-preauthorization-example-01.json

{
  "resourceType" : "Claim",
  "id" : "Claim-preauthorization-example-01",
  "meta" : {
    "profile" : ["https://nrces.in/ndhm/fhir/r4/StructureDefinition/Claim"]
  },
  "text" : {
    "status" : "generated",
    "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p class=\"res-header-id\"><b>Generated Narrative: Claim Claim-preauthorization-example-01</b></p><a name=\"Claim-preauthorization-example-01\"> </a><a name=\"hcClaim-preauthorization-example-01\"> </a><a name=\"Claim-preauthorization-example-01-hi-IN\"> </a><p><b>identifier</b>: 7612345</p><p><b>status</b>: Active</p><p><b>type</b>: <span title=\"Codes:{http://snomed.info/sct 737481003}\">Inpatient care management (procedure)</span></p><p><b>subType</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/ex-claimsubtype emergency}\">Emergency Claim</span></p><p><b>use</b>: Preauthorization</p><p><b>patient</b>: <a href=\"Patient-example-01.html\">ABC Male, DoB: 1981-01-12 ( Medical record number: 22-7225-4829-5255)</a></p><p><b>billablePeriod</b>: 2025-03-07 11:01:00+0500 --&gt; 2025-04-07 11:01:00+0500</p><p><b>created</b>: 2025-03-08 11:01:00+0500</p><p><b>insurer</b>: <a href=\"Organization-example-02.html\">Organization XYZ Insurance Co. Ltd.</a></p><p><b>provider</b>: <a href=\"Organization-example-03.html\">Organization XYZ Hospital Co. Ltd.</a></p><p><b>priority</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/processpriority normal}\">Normal</span></p><h3>CareTeams</h3><table class=\"grid\"><tr><td style=\"display: none\">-</td><td><b>Sequence</b></td><td><b>Provider</b></td><td><b>Role</b></td><td><b>Qualification</b></td></tr><tr><td style=\"display: none\">*</td><td>1</td><td><a href=\"Practitioner-example-01.html\">Practitioner Dr. DEF</a></td><td><span title=\"Codes:{http://snomed.info/sct 223366009}\">Healthcare professional (occupation)</span></td><td><span title=\"Codes:{http://snomed.info/sct 394658006}\">Clinical specialty (qualifier value)</span></td></tr></table><h3>Diagnoses</h3><table class=\"grid\"><tr><td style=\"display: none\">-</td><td><b>Sequence</b></td><td><b>Diagnosis[x]</b></td><td><b>Type</b></td></tr><tr><td style=\"display: none\">*</td><td>1</td><td><span title=\"Codes:{http://hl7.org/fhir/sid/icd-10 I46.9}\">Cardiac arrest, unspecified</span></td><td><span title=\"Codes:{http://snomed.info/sct 89100005}\">Final diagnosis (discharge) (contextual qualifier) (qualifier value)</span></td></tr></table><blockquote><p><b>procedure</b></p><p><b>sequence</b>: 1</p><p><b>procedure</b>: <span title=\"Codes:{http://snomed.info/sct 77343006}\">Angiography</span></p></blockquote><blockquote><p><b>procedure</b></p><p><b>sequence</b>: 2</p><p><b>procedure</b>: <span title=\"Codes:{http://snomed.info/sct 418285008}\">Angioplasty of blood vessel</span></p></blockquote><h3>Insurances</h3><table class=\"grid\"><tr><td style=\"display: none\">-</td><td><b>Sequence</b></td><td><b>Focal</b></td><td><b>Coverage</b></td></tr><tr><td style=\"display: none\">*</td><td>1</td><td>true</td><td><a href=\"Coverage-example-01.html\">Coverage: identifier = https://xyzinsurance.in/policynumber/#235037120; status = active; type = PAY; subscriberId = ABC123456BI007; relationship = Self; period = (?) --&gt; 2026-03-17</a></td></tr></table><blockquote><p><b>item</b></p><p><b>sequence</b>: 1</p><p><b>careTeamSequence</b>: 1</p><p><b>productOrService</b>: <span title=\"Codes:{http://snomed.info/sct 77343006}\">Angiography</span></p><h3>UnitPrices</h3><table class=\"grid\"><tr><td style=\"display: none\">-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td style=\"display: none\">*</td><td>10000</td><td>Indian rupee</td></tr></table><h3>Nets</h3><table class=\"grid\"><tr><td style=\"display: none\">-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td style=\"display: none\">*</td><td>10000</td><td>Indian rupee</td></tr></table></blockquote><blockquote><p><b>item</b></p><p><b>sequence</b>: 2</p><p><b>careTeamSequence</b>: 1</p><p><b>productOrService</b>: <span title=\"Codes:{http://snomed.info/sct 418285008}\">Angioplasty of blood vessel</span></p><h3>UnitPrices</h3><table class=\"grid\"><tr><td style=\"display: none\">-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td style=\"display: none\">*</td><td>40000</td><td>Indian rupee</td></tr></table><h3>Nets</h3><table class=\"grid\"><tr><td style=\"display: none\">-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td style=\"display: none\">*</td><td>40000</td><td>Indian rupee</td></tr></table></blockquote><blockquote><p><b>item</b></p><p><b>sequence</b>: 3</p><p><b>careTeamSequence</b>: 1</p><p><b>productOrService</b>: <span title=\"Codes:{http://snomed.info/sct 309904001}\">Intensive care unit</span></p><h3>UnitPrices</h3><table class=\"grid\"><tr><td style=\"display: none\">-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td style=\"display: none\">*</td><td>2000</td><td>Indian rupee</td></tr></table><h3>Nets</h3><table class=\"grid\"><tr><td style=\"display: none\">-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td style=\"display: none\">*</td><td>20000</td><td>Indian rupee</td></tr></table></blockquote><h3>Totals</h3><table class=\"grid\"><tr><td style=\"display: none\">-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td style=\"display: none\">*</td><td>70000</td><td>Indian rupee</td></tr></table></div>"
  },
  "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"
  }
}