FHIR Implementation Guide for HCX
0.8.0 - CI Build
FHIR Implementation Guide for HCX
0.8.0 - CI Build
FHIR Implementation Guide for HCX - Local Development build (v0.8.0). See the Directory of published versions
<Claim xmlns="http://hl7.org/fhir">
<id value="example-01"/>
<meta>
<versionId value="1"/>
<lastUpdated value="2020-10-07T03:26:09.060+00:00"/>
<source value="#BHZcRrcF4oS0JQ42"/>
</meta>
<text>
<status value="generated"/>
<div xmlns="http://www.w3.org/1999/xhtml"><p><b>Generated Narrative: Claim</b><a name="example-01"> </a></p><div style="display: inline-block; background-color: #d9e0e7; padding: 6px; margin: 4px; border: 1px solid #8da1b4; border-radius: 5px; line-height: 60%"><p style="margin-bottom: 0px">Resource Claim "example-01" Version "1" Updated "2020-10-07 03:26:09+0000" </p><p style="margin-bottom: 0px">Information Source: #BHZcRrcF4oS0JQ42!</p></div><p><b>identifier</b>: id: dc82673b-8c71-29js-8a17-16dj3i20352n</p><p><b>status</b>: active</p><p><b>type</b>: Institutional <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="http://terminology.hl7.org/5.0.0/CodeSystem-claim-type.html">Claim Type Codes</a>#institutional)</span></p><p><b>use</b>: claim</p><p><b>patient</b>: <span/></p><p><b>billablePeriod</b>: 1979-02-27 16:01:08-0500 --> 1979-02-28 16:01:08-0500</p><p><b>created</b>: 1979-02-28 16:01:08-0500</p><p><b>insurer</b>: <span/></p><p><b>provider</b>: <span/></p><p><b>priority</b>: Normal <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="http://terminology.hl7.org/5.0.0/CodeSystem-processpriority.html">Process Priority Codes</a>#normal)</span></p><h3>Payees</h3><table class="grid"><tr><td>-</td><td><b>Type</b></td><td><b>Party</b></td></tr><tr><td>*</td><td>Provider <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="http://terminology.hl7.org/5.0.0/CodeSystem-payeetype.html">Claim Payee Type Codes</a>#provider)</span></td><td><span/></td></tr></table><h3>CareTeams</h3><table class="grid"><tr><td>-</td><td><b>Sequence</b></td><td><b>Provider</b></td></tr><tr><td>*</td><td>1</td><td><span/></td></tr></table><blockquote><p><b>procedure</b></p><p><b>sequence</b>: 1</p><p><b>procedure</b>: PROC-1 <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="http://hl7.org/fhir/R4/codesystem-icd-10-procedures.html">ICD-10 Procedure Codes</a>#123001)</span></p></blockquote><blockquote><p><b>procedure</b></p><p><b>sequence</b>: 2</p><p><b>procedure</b>: PROC-2 <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="http://hl7.org/fhir/R4/codesystem-icd-10-procedures.html">ICD-10 Procedure Codes</a>#123002)</span></p></blockquote><blockquote><p><b>procedure</b></p><p><b>sequence</b>: 3</p><p><b>procedure</b>: PROC-3 <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="http://hl7.org/fhir/R4/codesystem-icd-10-procedures.html">ICD-10 Procedure Codes</a>#123003)</span></p></blockquote><h3>Insurances</h3><table class="grid"><tr><td>-</td><td><b>Sequence</b></td><td><b>Focal</b></td><td><b>Coverage</b></td></tr><tr><td>*</td><td>1</td><td>true</td><td><span>: Cigna Health</span></td></tr></table><blockquote><p><b>item</b></p><p><b>sequence</b>: 1</p><p><b>productOrService</b>: Encounter for problem <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="https://browser.ihtsdotools.org/">SNOMED CT</a>#185347001)</span></p></blockquote><blockquote><p><b>item</b></p><p><b>sequence</b>: 2</p><p><b>procedureSequence</b>: 1</p><p><b>productOrService</b>: Hearing examination (procedure) <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="https://browser.ihtsdotools.org/">SNOMED CT</a>#398171003)</span></p><h3>Nets</h3><table class="grid"><tr><td>-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td>*</td><td>516.65</td><td>USD</td></tr></table></blockquote><blockquote><p><b>item</b></p><p><b>sequence</b>: 3</p><p><b>procedureSequence</b>: 2</p><p><b>productOrService</b>: Combined chemotherapy and radiation therapy (procedure) <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="https://browser.ihtsdotools.org/">SNOMED CT</a>#703423002)</span></p><h3>Nets</h3><table class="grid"><tr><td>-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td>*</td><td>16924.49</td><td>USD</td></tr></table></blockquote><blockquote><p><b>item</b></p><p><b>sequence</b>: 4</p><p><b>procedureSequence</b>: 3</p><p><b>productOrService</b>: High resolution computed tomography of chest without contrast (procedure) <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="https://browser.ihtsdotools.org/">SNOMED CT</a>#16335031000119103)</span></p><h3>Nets</h3><table class="grid"><tr><td>-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td>*</td><td>516.65</td><td>USD</td></tr></table></blockquote><h3>Totals</h3><table class="grid"><tr><td>-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td>*</td><td>129.16</td><td>USD</td></tr></table></div>
</text>
<identifier>
<system value="https://www.tmh.in/claim-request"/>
<value value="dc82673b-8c71-29js-8a17-16dj3i20352n"/>
</identifier>
<status value="active"/>
<type>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/claim-type"/>
<code value="institutional"/>
</coding>
</type>
<use value="claim"/>
<patient id="RVH1003">
<identifier>
<type>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/v2-0203"/>
<code value="SN"/>
<display value="Subscriber Number"/>
</coding>
</type>
<system value="http://gicofIndia.com/beneficiaries"/>
<value value="BEN-101"/>
</identifier>
</patient>
<billablePeriod>
<start value="1979-02-27T16:01:08-05:00"/>
<end value="1979-02-28T16:01:08-05:00"/>
</billablePeriod>
<created value="1979-02-28T16:01:08-05:00"/>
<insurer id="GICOFINDIA">
<identifier>
<system value="http://irdai.gov.in/insurers"/>
<value value="112"/>
</identifier>
</insurer>
<provider id="Tmh01">
<identifier>
<system value="http://abdm.gov.in/facilities"/>
<value value="HFR-ID-FOR-TMH"/>
</identifier>
</provider>
<priority>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/processpriority"/>
<code value="normal"/>
</coding>
</priority>
<payee>
<type>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/payeetype"/>
<code value="provider"/>
</coding>
</type>
<party id="Tmh02">
<identifier>
<system value="http://abdm.gov.in/facilities"/>
<value value="HFR-ID-FOR-TMH"/>
</identifier>
</party>
</payee>
<careTeam>
<sequence value="1"/>
<provider id="Tmh03">
<identifier>
<system value="http://abdm.gov.in/facilities"/>
<value value="HFR-ID-FOR-TMH"/>
</identifier>
</provider>
</careTeam>
<procedure>
<sequence value="1"/>
<procedureCodeableConcept>
<coding>
<system value="http://hl7.org/fhir/sid/ex-icd-10-procedures"/>
<code value="123001"/>
</coding>
</procedureCodeableConcept>
</procedure>
<procedure>
<sequence value="2"/>
<procedureCodeableConcept>
<coding>
<system value="http://hl7.org/fhir/sid/ex-icd-10-procedures"/>
<code value="123002"/>
</coding>
</procedureCodeableConcept>
</procedure>
<procedure>
<sequence value="3"/>
<procedureCodeableConcept>
<coding>
<system value="http://hl7.org/fhir/sid/ex-icd-10-procedures"/>
<code value="123003"/>
</coding>
</procedureCodeableConcept>
</procedure>
<insurance>
<sequence value="1"/>
<focal value="true"/>
<coverage>
<display value="Cigna Health"/>
</coverage>
</insurance>
<item>
<sequence value="1"/>
<productOrService>
<coding>
<system value="http://snomed.info/sct"/>
<code value="185347001"/>
<display value="Encounter for problem"/>
</coding>
<text value="Encounter for problem"/>
</productOrService>
</item>
<item>
<sequence value="2"/>
<procedureSequence value="1"/>
<productOrService>
<coding>
<system value="http://snomed.info/sct"/>
<code value="398171003"/>
<display value="Hearing examination (procedure)"/>
</coding>
<text value="Hearing examination (procedure)"/>
</productOrService>
<net>
<value value="516.65"/>
<currency value="USD"/>
</net>
</item>
<item>
<sequence value="3"/>
<procedureSequence value="2"/>
<productOrService>
<coding>
<system value="http://snomed.info/sct"/>
<code value="703423002"/>
<display
value="Combined chemotherapy and radiation therapy (procedure)"/>
</coding>
<text value="Combined chemotherapy and radiation therapy (procedure)"/>
</productOrService>
<net>
<value value="16924.49"/>
<currency value="USD"/>
</net>
</item>
<item>
<sequence value="4"/>
<procedureSequence value="3"/>
<productOrService>
<coding>
<system value="http://snomed.info/sct"/>
<code value="16335031000119103"/>
<display
value="High resolution computed tomography of chest without contrast (procedure)"/>
</coding>
<text
value="High resolution computed tomography of chest without contrast (procedure)"/>
</productOrService>
<net>
<value value="516.65"/>
<currency value="USD"/>
</net>
</item>
<total>
<value value="129.16"/>
<currency value="USD"/>
</total>
</Claim>
IG © 2021+ HCX Open Community. Package hcxprotocol.io#0.8.0 based on FHIR 4.0.1. Generated 2023-03-15
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