LinuxForHealth FHIR Implementation Guide
8.0.0 - draft
LinuxForHealth FHIR Implementation Guide - Local Development build (v8.0.0). See the Directory of published versions
{
"resourceType" : "Claim",
"id" : "CDMClaimFacilityInstance",
"meta" : {
"extension" : [
{
"url" : "http://linuxforhealth.org/fhir/cdm/StructureDefinition/tenant-id",
"valueString" : "tenant7209"
},
{
"url" : "http://linuxforhealth.org/fhir/cdm/StructureDefinition/ingestion-batch-id",
"valueString" : "rgVCJnQBxvghkKTI8Hzz"
},
{
"url" : "http://linuxforhealth.org/fhir/cdm/StructureDefinition/process-name",
"valueString" : "TREX"
},
{
"url" : "http://linuxforhealth.org/fhir/cdm/StructureDefinition/process-client-id",
"valueString" : "7209"
},
{
"url" : "http://linuxforhealth.org/fhir/cdm/StructureDefinition/process-record-id",
"valueIdentifier" : {
"system" : "http://acme-health.com/WellnessMedicalFacility",
"value" : "7209_07869_e00080779_3938586_2516181"
}
},
{
"url" : "http://linuxforhealth.org/fhir/cdm/StructureDefinition/source-file-id",
"valueString" : "e00030779"
}
],
"source" : "http://acme-health.com/WellnessMedicalFacility",
"profile" : [
"http://linuxforhealth.org/fhir/cdm/StructureDefinition/cdm-claim-facility"
]
},
"text" : {
"status" : "extensions",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p><b>Generated Narrative: Claim</b><a name=\"CDMClaimFacilityInstance\"> </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 \"CDMClaimFacilityInstance\" </p><p style=\"margin-bottom: 0px\">Information Source: http://acme-health.com/WellnessMedicalFacility!</p><p style=\"margin-bottom: 0px\">Profile: <a href=\"StructureDefinition-cdm-claim-facility.html\">CDM Claim Facility</a></p></div><p><b>Admit Count</b>: 1</p><p><b>Aggregate Claim Indicator</b>: N</p><p><b>Claim Category</b>: F0 <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (claim-status-category-codes#F0)</span></p><p><b>Claim Status</b>: F0 <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (claim-status-codes#F0)</span></p><p><b>Claim Snapshot Provider Name</b>: Dr Smith</p><p><b>Claim Snapshot Provider Zip Code</b>: 79912</p><p><b>Employer</b>: EmployerCode <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (local-employer-code#EmployerCode)</span></p><p><b>Employee Business Unit</b>: EmpBusUnit <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (local-employee-business-unit#EmpBusUnit)</span></p><p><b>Financial System</b>: LocFinanceSys <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (local-financial-system#LocFinanceSys)</span></p><p><b>Last Claim Indicator</b>: Y</p><p><b>Participating Plan</b>: LocParticipatingPlan <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (local-participating-plan#LocParticipatingPlan)</span></p><p><b>Referral Indicator</b>: N</p><p><b>Snapshot Age In Years</b>: 20</p><p><b>Submission Type</b>: SubmitType <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (local-submission-type#SubmitType)</span></p><p><b>Payer PCP Responsibility Indicator</b>: N</p><p><b>identifier</b>: Source System Row Identifier: 000000000000000000019721078(use: OFFICIAL), Source System Row Identifier: 99999999999(use: SECONDARY)</p><p><b>status</b>: active</p><p><b>type</b>: Medical claim; Institutional/Professional unknown <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-payer-claim-type.html\">Payer Claim Type Codes</a>#medical; local-claim-type#Medical)</span></p><p><b>subType</b>: Emergency <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-claim-subtype.html\">Claim Subtype Codes</a>#emergency)</span></p><p><b>use</b>: claim</p><p><b>patient</b>: <a href=\"Patient-CDMPatientInstance.html\">Patient/CDMPatientInstance</a> \" MCLASTNAME\"</p><p><b>billablePeriod</b>: 2017-06-02 --> 2017-06-02</p><p><b>created</b>: 2017-07-25 05:31:00-0500</p><p><b>provider</b>: <a href=\"Organization-Provider1.html\">Organization/Provider1</a> \"Dr Smith\"</p><p><b>priority</b>: Normal <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"http://terminology.hl7.org/4.0.0/CodeSystem-processpriority.html\">Process Priority Codes</a>#normal)</span></p><p><b>referral</b>: <a href=\"ServiceRequest-CDMServiceRequestInstance.html\">ServiceRequest/CDMServiceRequestInstance</a></p><blockquote><p><b>careTeam</b></p><p><b>sequence</b>: 1</p><p><b>provider</b>: <a href=\"Practitioner-DrKelly.html\">Practitioner/DrKelly</a> \" KELLY\"</p><p><b>role</b>: Ordering provider <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-claim-care-team-role.html\">Claim Care Team Role Codes</a>#ordering)</span></p></blockquote><blockquote><p><b>careTeam</b></p><p><b>sequence</b>: 2</p><p><b>provider</b>: <a href=\"Practitioner-DrSmith.html\">Practitioner/DrSmith</a> \" SMITH\"</p><p><b>role</b>: Admitting provider <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-claim-care-team-role.html\">Claim Care Team Role Codes</a>#admitting)</span></p></blockquote><blockquote><p><b>careTeam</b></p><p><b>sequence</b>: 3</p><p><b>provider</b>: <a href=\"Practitioner-DrKelly.html\">Practitioner/DrKelly</a> \" KELLY\"</p><p><b>role</b>: Attending provider <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-claim-care-team-role.html\">Claim Care Team Role Codes</a>#attending)</span></p></blockquote><blockquote><p><b>careTeam</b></p><p><b>sequence</b>: 4</p><p><b>provider</b>: <a href=\"Organization-Provider1.html\">Organization/Provider1</a> \"Dr Smith\"</p><p><b>role</b>: Servicing provider <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-claim-care-team-role.html\">Claim Care Team Role Codes</a>#servicing)</span></p><p><b>qualification</b>: 01 <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (local-specialty#01)</span></p></blockquote><blockquote><p><b>supportingInfo</b></p><p><b>sequence</b>: 1</p><p><b>category</b>: Information <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"http://terminology.hl7.org/4.0.0/CodeSystem-claiminformationcategory.html\">Claim Information Category Codes</a>#info)</span></p><p><b>code</b>: Capitated service indicator <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-claim-supporting-info-type.html\">Claim Supporting Info Type Codes</a>#capitated-service-indicator)</span></p><p><b>value</b>: N</p></blockquote><blockquote><p><b>supportingInfo</b></p><p><b>sequence</b>: 2</p><p><b>category</b>: Other <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"http://terminology.hl7.org/4.0.0/CodeSystem-claiminformationcategory.html\">Claim Information Category Codes</a>#other)</span></p><p><b>code</b>: Emergency Room <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-er-or-observation-room-service.html\">Er Or Observation Room Service Codes</a>#1)</span></p></blockquote><blockquote><p><b>supportingInfo</b></p><p><b>sequence</b>: 3</p><p><b>category</b>: Hospitalized <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"http://terminology.hl7.org/4.0.0/CodeSystem-claiminformationcategory.html\">Claim Information Category Codes</a>#hospitalized)</span></p><p><b>timing</b>: 2017-06-02 --> 2017-06-02</p></blockquote><blockquote><p><b>supportingInfo</b></p><p><b>sequence</b>: 4</p><p><b>category</b>: Hospitalized <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"http://terminology.hl7.org/4.0.0/CodeSystem-claiminformationcategory.html\">Claim Information Category Codes</a>#hospitalized)</span></p><p><b>code</b>: Emergency <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-ub04-admit-type.html\">UB04 Admit Type Code System</a>#1)</span></p></blockquote><blockquote><p><b>supportingInfo</b></p><p><b>sequence</b>: 5</p><p><b>category</b>: Hospitalized <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"http://terminology.hl7.org/4.0.0/CodeSystem-claiminformationcategory.html\">Claim Information Category Codes</a>#hospitalized)</span></p><p><b>code</b>: Hospital / Level I Intermediate Care / Admit Through Discharge Claim <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-ub04-admit-bill-type.html\">UB04 Admit Bill Type Code System</a>#0151)</span></p></blockquote><blockquote><p><b>supportingInfo</b></p><p><b>sequence</b>: 6</p><p><b>category</b>: Hospitalized <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"http://terminology.hl7.org/4.0.0/CodeSystem-claiminformationcategory.html\">Claim Information Category Codes</a>#hospitalized)</span></p><p><b>code</b>: Days count <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-claim-supporting-info-type.html\">Claim Supporting Info Type Codes</a>#days-count)</span></p><p><b>value</b>: 3 /d</p></blockquote><blockquote><p><b>supportingInfo</b></p><p><b>sequence</b>: 7</p><p><b>category</b>: Discharge <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"http://terminology.hl7.org/4.0.0/CodeSystem-claiminformationcategory.html\">Claim Information Category Codes</a>#discharge)</span></p><p><b>code</b>: 11 <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (patient-discharge#11)</span></p></blockquote><blockquote><p><b>supportingInfo</b></p><p><b>sequence</b>: 8</p><p><b>category</b>: Other <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"http://terminology.hl7.org/4.0.0/CodeSystem-claiminformationcategory.html\">Claim Information Category Codes</a>#other)</span></p><p><b>code</b>: Room and Board <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-room-and-board-service.html\">Room And Board Service Codes</a>#1)</span></p></blockquote><blockquote><p><b>supportingInfo</b></p><p><b>sequence</b>: 9</p><p><b>category</b>: Information <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"http://terminology.hl7.org/4.0.0/CodeSystem-claiminformationcategory.html\">Claim Information Category Codes</a>#info)</span></p><p><b>code</b>: Network provider indicator <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-claim-supporting-info-type.html\">Claim Supporting Info Type Codes</a>#network-provider-indicator)</span></p><p><b>value</b>: Y</p></blockquote><blockquote><p><b>supportingInfo</b></p><p><b>sequence</b>: 10</p><p><b>category</b>: Hospitalized <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"http://terminology.hl7.org/4.0.0/CodeSystem-claiminformationcategory.html\">Claim Information Category Codes</a>#hospitalized)</span></p><p><b>code</b>: Admission hour <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-claim-supporting-info-type.html\">Claim Supporting Info Type Codes</a>#admission-hour)</span></p><p><b>value</b>: 07</p></blockquote><blockquote><p><b>supportingInfo</b></p><p><b>sequence</b>: 11</p><p><b>category</b>: Hospitalized <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"http://terminology.hl7.org/4.0.0/CodeSystem-claiminformationcategory.html\">Claim Information Category Codes</a>#hospitalized)</span></p><p><b>code</b>: Days count <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-claim-supporting-info-type.html\">Claim Supporting Info Type Codes</a>#days-count)</span></p><p><b>value</b>: 3 /d</p></blockquote><blockquote><p><b>supportingInfo</b></p><p><b>sequence</b>: 12</p><p><b>category</b>: Hospitalized <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"http://terminology.hl7.org/4.0.0/CodeSystem-claiminformationcategory.html\">Claim Information Category Codes</a>#hospitalized)</span></p><p><b>code</b>: Days not covered <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-claim-supporting-info-type.html\">Claim Supporting Info Type Codes</a>#days-not-covered)</span></p><p><b>value</b>: 1 /d</p></blockquote><blockquote><p><b>supportingInfo</b></p><p><b>sequence</b>: 13</p><p><b>category</b>: Hospitalized <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"http://terminology.hl7.org/4.0.0/CodeSystem-claiminformationcategory.html\">Claim Information Category Codes</a>#hospitalized)</span></p><p><b>code</b>: Days longterm care recipient on leave <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-claim-supporting-info-type.html\">Claim Supporting Info Type Codes</a>#days-long-term-care-recipient-on-leave)</span></p><p><b>value</b>: 0 /d</p></blockquote><blockquote><p><b>supportingInfo</b></p><p><b>sequence</b>: 14</p><p><b>category</b>: Hospitalized <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"http://terminology.hl7.org/4.0.0/CodeSystem-claiminformationcategory.html\">Claim Information Category Codes</a>#hospitalized)</span></p><p><b>code</b>: Newbord length of stay <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-claim-supporting-info-type.html\">Claim Supporting Info Type Codes</a>#newborn-length-of-stay)</span></p><p><b>value</b>: 0 /d</p></blockquote><blockquote><p><b>supportingInfo</b></p><p><b>sequence</b>: 15</p><p><b>category</b>: Information <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"http://terminology.hl7.org/4.0.0/CodeSystem-claiminformationcategory.html\">Claim Information Category Codes</a>#info)</span></p><p><b>code</b>: Onset of symptoms/illness <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"http://terminology.hl7.org/4.0.0/CodeSystem-v2-0350.html\">nubc-OccurrenceCode-cs</a>#11)</span></p><p><b>timing</b>: 2017-06-02 --> 2017-06-02</p></blockquote><blockquote><p><b>supportingInfo</b></p><p><b>sequence</b>: 16</p><p><b>category</b>: Information <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"http://terminology.hl7.org/4.0.0/CodeSystem-claiminformationcategory.html\">Claim Information Category Codes</a>#info)</span></p><p><b>code</b>: Acquired Condition Indicator <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-claim-supporting-info-type.html\">Claim Supporting Info Type Codes</a>#acquired-condition-indicator)</span></p></blockquote><blockquote><p><b>supportingInfo</b></p><p><b>sequence</b>: 17</p><p><b>category</b>: Hospitalized <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"http://terminology.hl7.org/4.0.0/CodeSystem-claiminformationcategory.html\">Claim Information Category Codes</a>#hospitalized)</span></p><p><b>code</b>: Discharge hour <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-claim-supporting-info-type.html\">Claim Supporting Info Type Codes</a>#discharge-hour)</span></p><p><b>value</b>: 22</p></blockquote><blockquote><p><b>diagnosis</b></p><p><b>sequence</b>: 1</p><p><b>diagnosis</b>: Headache <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"http://terminology.hl7.org/4.0.0/CodeSystem-icd10CM.html\">International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM)</a>#R51)</span></p><p><b>type</b>: Principal Diagnosis <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"http://terminology.hl7.org/4.0.0/CodeSystem-ex-diagnosistype.html\">Example Diagnosis Type Codes</a>#principal)</span></p><p><b>onAdmission</b>: Yes, present ad admission <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-diagnosis-present-on-admission.html\">Diagnosis Present On Admission Codes</a>#Y)</span></p><p><b>packageCode</b>: 102 <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (P0002.html#102)</span></p></blockquote><blockquote><p><b>diagnosis</b></p><p><b>sequence</b>: 2</p><p><b>diagnosis</b>: Migraine, Unspecified, not Intractable, without Status Migrainosus <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"http://terminology.hl7.org/4.0.0/CodeSystem-icd10CM.html\">International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM)</a>#G43.909)</span></p><p><b>type</b>: Discharge Diagnosis <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"http://terminology.hl7.org/4.0.0/CodeSystem-ex-diagnosistype.html\">Example Diagnosis Type Codes</a>#discharge)</span></p><p><b>onAdmission</b>: No, not present at admission <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-diagnosis-present-on-admission.html\">Diagnosis Present On Admission Codes</a>#N)</span></p></blockquote><blockquote><p><b>diagnosis</b></p><p><b>sequence</b>: 3</p><p><b>diagnosis</b>: Migraine, unspecified <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"http://terminology.hl7.org/4.0.0/CodeSystem-icd10CM.html\">International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM)</a>#G43.9)</span></p><p><b>type</b>: Admitting Diagnosis <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"http://terminology.hl7.org/4.0.0/CodeSystem-ex-diagnosistype.html\">Example Diagnosis Type Codes</a>#admitting)</span></p></blockquote><blockquote><p><b>diagnosis</b></p><p><b>sequence</b>: 4</p><p><b>diagnosis</b>: Fall on and from ladder, initial encounter <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"http://terminology.hl7.org/4.0.0/CodeSystem-icd10CM.html\">International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM)</a>#W11.XXXA)</span></p><p><b>type</b>: External Cause <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-diagnosis-type.html\">Diagnosis Type Codes</a>#external-cause)</span></p></blockquote><blockquote><p><b>procedure</b></p><p><b>sequence</b>: 1</p><p><b>type</b>: surgical <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-procedure-type.html\">Procedure Type Codes</a>#surgical)</span></p><p><b>procedure</b>: Special EEG Tests <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"http://terminology.hl7.org/4.0.0/CodeSystem-CPT.html\">Current Procedural Terminology (CPT®)</a>#95958)</span></p></blockquote><blockquote><p><b>procedure</b></p><p><b>sequence</b>: 2</p><p><b>type</b>: surgical <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-procedure-type.html\">Procedure Type Codes</a>#surgical)</span></p><p><b>procedure</b>: Autologous blood or component, collection processing and storage <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"http://terminology.hl7.org/4.0.0/CodeSystem-CPT.html\">Current Procedural Terminology (CPT®)</a>#86891)</span></p></blockquote><h3>Insurances</h3><table class=\"grid\"><tr><td>-</td><td><b>Extension</b></td><td><b>Sequence</b></td><td><b>Focal</b></td><td><b>Identifier</b></td><td><b>Coverage</b></td><td><b>PreAuthRef</b></td></tr><tr><td>*</td><td>, </td><td>1</td><td>true</td><td>id: PPOB</td><td><a href=\"Coverage-CoverageExample.html\">Coverage/CoverageExample</a></td><td>PreAuth12345</td></tr></table><h3>Accidents</h3><table class=\"grid\"><tr><td>-</td><td><b>Date</b></td><td><b>Type</b></td></tr><tr><td>*</td><td>1900-01-01</td><td>No <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-payer-indicators.html\">Payer Indicator Codes</a>#N)</span></td></tr></table><h3>Items</h3><table class=\"grid\"><tr><td>-</td><td><b>Extension</b></td><td><b>Sequence</b></td><td><b>CareTeamSequence</b></td><td><b>Revenue</b></td><td><b>ProductOrService</b></td><td><b>Modifier</b></td><td><b>Serviced[x]</b></td><td><b>Location[x]</b></td><td><b>Quantity</b></td></tr><tr><td>*</td><td>, , , </td><td>1</td><td>2</td><td>Emergency Room <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (RevenueCodes#0450)</span></td><td>superficial muscle biopsy <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"http://terminology.hl7.org/4.0.0/CodeSystem-CPT.html\">Current Procedural Terminology (CPT®)</a>#20200; local-service-type#LocalServiceType)</span></td><td>Primary physician <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-procedure-modifier.html\">Procedure Modifier Codes</a>#AG)</span></td><td>2017-06-02</td><td>Office <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"http://terminology.hl7.org/4.0.0/CodeSystem-CMSPlaceofServiceCodes.html\">CMS Place of Service Codes (POS)</a>#11; local-place-of-service#LocalPlcOfService)</span></td><td>3</td></tr></table></div>"
},
"extension" : [
{
"url" : "http://linuxforhealth.org/fhir/cdm/StructureDefinition/admit-count",
"valueInteger" : 1
},
{
"url" : "http://linuxforhealth.org/fhir/cdm/StructureDefinition/aggregate-claim-indicator",
"valueString" : "N"
},
{
"url" : "http://linuxforhealth.org/fhir/cdm/StructureDefinition/claim-category",
"valueCodeableConcept" : {
"coding" : [
{
"system" : "https://x12.org/codes/claim-status-category-codes",
"code" : "F0"
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]
}
},
{
"url" : "http://linuxforhealth.org/fhir/cdm/StructureDefinition/claim-status",
"valueCodeableConcept" : {
"coding" : [
{
"system" : "https://x12.org/codes/claim-status-codes",
"code" : "F0"
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}
},
{
"url" : "http://linuxforhealth.org/fhir/cdm/StructureDefinition/claim-snapshot-provider-name",
"valueString" : "Dr Smith"
},
{
"url" : "http://linuxforhealth.org/fhir/cdm/StructureDefinition/claim-snapshot-provider-zip-code",
"valueString" : "79912"
},
{
"url" : "http://linuxforhealth.org/fhir/cdm/StructureDefinition/employer",
"valueCodeableConcept" : {
"coding" : [
{
"system" : "http://acme-health.com/CodeSystem/local-employer-code",
"code" : "EmployerCode"
}
]
}
},
{
"url" : "http://linuxforhealth.org/fhir/cdm/StructureDefinition/employee-business-unit",
"valueCodeableConcept" : {
"coding" : [
{
"system" : "http://acme-health.com/CodeSystem/local-employee-business-unit",
"code" : "EmpBusUnit"
}
]
}
},
{
"url" : "http://linuxforhealth.org/fhir/cdm/StructureDefinition/financial-system",
"valueCodeableConcept" : {
"coding" : [
{
"system" : "http://acme-health.com/CodeSystem/local-financial-system",
"code" : "LocFinanceSys"
}
]
}
},
{
"url" : "http://linuxforhealth.org/fhir/cdm/StructureDefinition/last-claim-indicator",
"valueString" : "Y"
},
{
"url" : "http://linuxforhealth.org/fhir/cdm/StructureDefinition/participating-plan",
"valueCodeableConcept" : {
"coding" : [
{
"system" : "http://acme-health.com/CodeSystem/local-participating-plan",
"code" : "LocParticipatingPlan"
}
]
}
},
{
"url" : "http://linuxforhealth.org/fhir/cdm/StructureDefinition/referral-indicator",
"valueString" : "N"
},
{
"url" : "http://linuxforhealth.org/fhir/cdm/StructureDefinition/snapshot-age-in-years",
"valueUnsignedInt" : 20
},
{
"url" : "http://linuxforhealth.org/fhir/cdm/StructureDefinition/submission-type",
"valueCodeableConcept" : {
"coding" : [
{
"system" : "http://acme-health.com/CodeSystem/local-submission-type",
"code" : "SubmitType"
}
]
}
},
{
"url" : "http://linuxforhealth.org/fhir/cdm/StructureDefinition/payer-pcp-responsibility-indicator",
"valueString" : "N"
}
],
"identifier" : [
{
"use" : "official",
"type" : {
"coding" : [
{
"system" : "http://linuxforhealth.org/fhir/cdm/CodeSystem/identifier-type",
"code" : "SSRI"
}
]
},
"system" : "http://acme-health.com/CodeSystem/local-claim-identifier",
"value" : "000000000000000000019721078",
"assigner" : {
"display" : "Acme Health - Wellness Medical Facility"
}
},
{
"use" : "secondary",
"type" : {
"coding" : [
{
"system" : "http://linuxforhealth.org/fhir/cdm/CodeSystem/identifier-type",
"code" : "SSRI"
}
]
},
"system" : "http://acme-health.com/CodeSystem/local-authorization-identifier",
"value" : "99999999999",
"assigner" : {
"display" : "Acme Health - Wellness Medical Facility Corporate Office"
}
}
],
"status" : "active",
"type" : {
"coding" : [
{
"system" : "http://linuxforhealth.org/fhir/cdm/CodeSystem/payer-claim-type",
"code" : "medical"
},
{
"system" : "http://acme-health.com/CodeSystem/local-claim-type",
"code" : "Medical"
}
]
},
"subType" : {
"coding" : [
{
"system" : "http://linuxforhealth.org/fhir/cdm/CodeSystem/claim-subtype",
"code" : "emergency"
}
]
},
"use" : "claim",
"patient" : {
"reference" : "Patient/CDMPatientInstance"
},
"billablePeriod" : {
"start" : "2017-06-02",
"end" : "2017-06-02"
},
"created" : "2017-07-25T17:31:00-05:00",
"provider" : {
"reference" : "Organization/Provider1"
},
"priority" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/processpriority",
"code" : "normal"
}
]
},
"referral" : {
"reference" : "ServiceRequest/CDMServiceRequestInstance"
},
"careTeam" : [
{
"sequence" : 1,
"provider" : {
"reference" : "Practitioner/DrKelly"
},
"role" : {
"coding" : [
{
"system" : "http://linuxforhealth.org/fhir/cdm/CodeSystem/claim-care-team-role",
"code" : "ordering"
}
]
}
},
{
"sequence" : 2,
"provider" : {
"reference" : "Practitioner/DrSmith"
},
"role" : {
"coding" : [
{
"system" : "http://linuxforhealth.org/fhir/cdm/CodeSystem/claim-care-team-role",
"code" : "admitting"
}
]
}
},
{
"sequence" : 3,
"provider" : {
"reference" : "Practitioner/DrKelly"
},
"role" : {
"coding" : [
{
"system" : "http://linuxforhealth.org/fhir/cdm/CodeSystem/claim-care-team-role",
"code" : "attending"
}
]
}
},
{
"sequence" : 4,
"provider" : {
"reference" : "Organization/Provider1"
},
"role" : {
"coding" : [
{
"system" : "http://linuxforhealth.org/fhir/cdm/CodeSystem/claim-care-team-role",
"code" : "servicing"
}
]
},
"qualification" : {
"coding" : [
{
"system" : "http://acme-health.com/CodeSystem/local-specialty",
"code" : "01"
}
]
}
}
],
"supportingInfo" : [
{
"sequence" : 1,
"category" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/claiminformationcategory",
"code" : "info"
}
]
},
"code" : {
"coding" : [
{
"system" : "http://linuxforhealth.org/fhir/cdm/CodeSystem/claim-supporting-info-type",
"code" : "capitated-service-indicator"
}
]
},
"valueString" : "N"
},
{
"sequence" : 2,
"category" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/claiminformationcategory",
"code" : "other"
}
]
},
"code" : {
"coding" : [
{
"system" : "http://linuxforhealth.org/fhir/cdm/CodeSystem/er-or-observation-room-service",
"code" : "1"
}
]
}
},
{
"sequence" : 3,
"category" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/claiminformationcategory",
"code" : "hospitalized"
}
]
},
"timingPeriod" : {
"start" : "2017-06-02",
"end" : "2017-06-02"
}
},
{
"sequence" : 4,
"category" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/claiminformationcategory",
"code" : "hospitalized"
}
]
},
"code" : {
"coding" : [
{
"system" : "http://linuxforhealth.org/fhir/cdm/CodeSystem/ub04-admit-type",
"code" : "1"
}
]
}
},
{
"sequence" : 5,
"category" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/claiminformationcategory",
"code" : "hospitalized"
}
]
},
"code" : {
"coding" : [
{
"system" : "http://linuxforhealth.org/fhir/cdm/CodeSystem/ub04-admit-bill-type",
"code" : "0151"
}
]
}
},
{
"sequence" : 6,
"category" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/claiminformationcategory",
"code" : "hospitalized"
}
]
},
"code" : {
"coding" : [
{
"system" : "http://linuxforhealth.org/fhir/cdm/CodeSystem/claim-supporting-info-type",
"code" : "days-count"
}
]
},
"valueQuantity" : {
"value" : 3,
"unit" : "/d",
"system" : "http://unitsofmeasure.org"
}
},
{
"sequence" : 7,
"category" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/claiminformationcategory",
"code" : "discharge"
}
]
},
"code" : {
"coding" : [
{
"system" : "https://www.nubc.org/patient-discharge",
"code" : "11"
}
]
}
},
{
"sequence" : 8,
"category" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/claiminformationcategory",
"code" : "other"
}
]
},
"code" : {
"coding" : [
{
"system" : "http://linuxforhealth.org/fhir/cdm/CodeSystem/room-and-board-service",
"code" : "1"
}
]
}
},
{
"sequence" : 9,
"category" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/claiminformationcategory",
"code" : "info"
}
]
},
"code" : {
"coding" : [
{
"system" : "http://linuxforhealth.org/fhir/cdm/CodeSystem/claim-supporting-info-type",
"code" : "network-provider-indicator"
}
]
},
"valueString" : "Y"
},
{
"sequence" : 10,
"category" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/claiminformationcategory",
"code" : "hospitalized"
}
]
},
"code" : {
"coding" : [
{
"system" : "http://linuxforhealth.org/fhir/cdm/CodeSystem/claim-supporting-info-type",
"code" : "admission-hour"
}
]
},
"valueString" : "07"
},
{
"sequence" : 11,
"category" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/claiminformationcategory",
"code" : "hospitalized"
}
]
},
"code" : {
"coding" : [
{
"system" : "http://linuxforhealth.org/fhir/cdm/CodeSystem/claim-supporting-info-type",
"code" : "days-count"
}
]
},
"valueQuantity" : {
"value" : 3,
"unit" : "/d",
"system" : "http://unitsofmeasure.org"
}
},
{
"sequence" : 12,
"category" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/claiminformationcategory",
"code" : "hospitalized"
}
]
},
"code" : {
"coding" : [
{
"system" : "http://linuxforhealth.org/fhir/cdm/CodeSystem/claim-supporting-info-type",
"code" : "days-not-covered"
}
]
},
"valueQuantity" : {
"value" : 1,
"unit" : "/d",
"system" : "http://unitsofmeasure.org"
}
},
{
"sequence" : 13,
"category" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/claiminformationcategory",
"code" : "hospitalized"
}
]
},
"code" : {
"coding" : [
{
"system" : "http://linuxforhealth.org/fhir/cdm/CodeSystem/claim-supporting-info-type",
"code" : "days-long-term-care-recipient-on-leave"
}
]
},
"valueQuantity" : {
"value" : 0,
"unit" : "/d",
"system" : "http://unitsofmeasure.org"
}
},
{
"sequence" : 14,
"category" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/claiminformationcategory",
"code" : "hospitalized"
}
]
},
"code" : {
"coding" : [
{
"system" : "http://linuxforhealth.org/fhir/cdm/CodeSystem/claim-supporting-info-type",
"code" : "newborn-length-of-stay"
}
]
},
"valueQuantity" : {
"value" : 0,
"unit" : "/d",
"system" : "http://unitsofmeasure.org"
}
},
{
"sequence" : 15,
"category" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/claiminformationcategory",
"code" : "info"
}
]
},
"code" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/v2-0350",
"code" : "11"
}
]
},
"timingPeriod" : {
"start" : "2017-06-02",
"end" : "2017-06-02"
}
},
{
"sequence" : 16,
"category" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/claiminformationcategory",
"code" : "info"
}
]
},
"code" : {
"coding" : [
{
"system" : "http://linuxforhealth.org/fhir/cdm/CodeSystem/claim-supporting-info-type",
"code" : "acquired-condition-indicator"
}
]
}
},
{
"sequence" : 17,
"category" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/claiminformationcategory",
"code" : "hospitalized"
}
]
},
"code" : {
"coding" : [
{
"system" : "http://linuxforhealth.org/fhir/cdm/CodeSystem/claim-supporting-info-type",
"code" : "discharge-hour"
}
]
},
"valueString" : "22"
}
],
"diagnosis" : [
{
"sequence" : 1,
"diagnosisCodeableConcept" : {
"coding" : [
{
"system" : "http://hl7.org/fhir/sid/icd-10-cm",
"code" : "R51",
"display" : "Headache"
}
]
},
"type" : [
{
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/ex-diagnosistype",
"code" : "principal"
}
]
}
],
"onAdmission" : {
"coding" : [
{
"system" : "http://linuxforhealth.org/fhir/cdm/CodeSystem/diagnosis-present-on-admission",
"code" : "Y"
}
]
},
"packageCode" : {
"coding" : [
{
"system" : "https://www.cms.gov/icd10m/version37-fullcode-cms/fullcode_cms/P0002.html",
"code" : "102"
}
]
}
},
{
"sequence" : 2,
"diagnosisCodeableConcept" : {
"coding" : [
{
"system" : "http://hl7.org/fhir/sid/icd-10-cm",
"code" : "G43.909",
"display" : "Migraine, Unspecified, not Intractable, without Status Migrainosus"
}
]
},
"type" : [
{
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/ex-diagnosistype",
"code" : "discharge"
}
]
}
],
"onAdmission" : {
"coding" : [
{
"system" : "http://linuxforhealth.org/fhir/cdm/CodeSystem/diagnosis-present-on-admission",
"code" : "N"
}
]
}
},
{
"sequence" : 3,
"diagnosisCodeableConcept" : {
"coding" : [
{
"system" : "http://hl7.org/fhir/sid/icd-10-cm",
"code" : "G43.9",
"display" : "Migraine, unspecified"
}
]
},
"type" : [
{
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/ex-diagnosistype",
"code" : "admitting"
}
]
}
]
},
{
"sequence" : 4,
"diagnosisCodeableConcept" : {
"coding" : [
{
"system" : "http://hl7.org/fhir/sid/icd-10-cm",
"code" : "W11.XXXA",
"display" : "Fall on and from ladder, initial encounter"
}
]
},
"type" : [
{
"coding" : [
{
"system" : "http://linuxforhealth.org/fhir/cdm/CodeSystem/diagnosis-type",
"code" : "external-cause"
}
]
}
]
}
],
"procedure" : [
{
"sequence" : 1,
"type" : [
{
"coding" : [
{
"system" : "http://linuxforhealth.org/fhir/cdm/CodeSystem/procedure-type",
"code" : "surgical"
}
]
}
],
"procedureCodeableConcept" : {
"coding" : [
{
"system" : "http://www.ama-assn.org/go/cpt",
"code" : "95958",
"display" : "Special EEG Tests"
}
]
}
},
{
"sequence" : 2,
"type" : [
{
"coding" : [
{
"system" : "http://linuxforhealth.org/fhir/cdm/CodeSystem/procedure-type",
"code" : "surgical"
}
]
}
],
"procedureCodeableConcept" : {
"coding" : [
{
"system" : "http://www.ama-assn.org/go/cpt",
"code" : "86891",
"display" : "Autologous blood or component, collection processing and storage"
}
]
}
}
],
"insurance" : [
{
"extension" : [
{
"url" : "http://linuxforhealth.org/fhir/cdm/StructureDefinition/crossover-indicator",
"valueString" : "N"
},
{
"url" : "http://linuxforhealth.org/fhir/cdm/StructureDefinition/prior-authorization-indicator",
"valueString" : "Y"
}
],
"sequence" : 1,
"focal" : true,
"identifier" : {
"system" : "http://acme-health.com/BCBS",
"value" : "PPOB"
},
"coverage" : {
"reference" : "Coverage/CoverageExample"
},
"preAuthRef" : [
"PreAuth12345"
]
}
],
"accident" : {
"date" : "1900-01-01",
"type" : {
"coding" : [
{
"system" : "http://linuxforhealth.org/fhir/cdm/CodeSystem/payer-indicators",
"code" : "N"
}
]
}
},
"item" : [
{
"extension" : [
{
"url" : "http://linuxforhealth.org/fhir/cdm/StructureDefinition/capitated-service-indicator",
"valueString" : "N"
},
{
"url" : "http://linuxforhealth.org/fhir/cdm/StructureDefinition/fully-insured-indicator",
"valueString" : "Y"
},
{
"url" : "http://linuxforhealth.org/fhir/cdm/StructureDefinition/nursing-home-indicator",
"valueString" : "N"
},
{
"url" : "http://linuxforhealth.org/fhir/cdm/StructureDefinition/service-bill-days-count",
"valueUnsignedInt" : 20
}
],
"sequence" : 1,
"careTeamSequence" : [
2
],
"revenue" : {
"coding" : [
{
"system" : "https://www.nubc.org/RevenueCodes",
"code" : "0450",
"display" : "Emergency Room"
}
]
},
"productOrService" : {
"coding" : [
{
"system" : "http://www.ama-assn.org/go/cpt",
"code" : "20200",
"display" : "superficial muscle biopsy"
},
{
"system" : "http://acme-health.com/CodeSystem/local-service-type",
"code" : "LocalServiceType"
}
]
},
"modifier" : [
{
"coding" : [
{
"system" : "http://linuxforhealth.org/fhir/cdm/CodeSystem/procedure-modifier",
"code" : "AG"
}
]
}
],
"servicedDate" : "2017-06-02",
"locationCodeableConcept" : {
"coding" : [
{
"system" : "https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set",
"code" : "11",
"display" : "Office"
},
{
"system" : "http://acme-health.com/CodeSystem/local-place-of-service",
"code" : "LocalPlcOfService"
}
]
},
"quantity" : {
"extension" : [
{
"url" : "http://linuxforhealth.org/fhir/cdm/StructureDefinition/local-number-of-units-per-service",
"valueQuantity" : {
"value" : 5
}
}
],
"value" : 3
}
}
]
}
IG © 2021+ LinuxForHealth Team. Package linuxforhealth.fhir.ig#8.0.0 based on FHIR 4.0.1. Generated 2022-11-10
Links: Table of Contents |
QA Report