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" : "CDMClaimProfessionalInstance",
"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/WellnessMedicalCenter",
"value" : "7209_07869_e00080779_3938586_2516181"
}
},
{
"url" : "http://linuxforhealth.org/fhir/cdm/StructureDefinition/source-file-id",
"valueString" : "e00080779"
}
],
"source" : "http://acme-health.com/WellnessMedicalCenter",
"profile" : [
"http://linuxforhealth.org/fhir/cdm/StructureDefinition/cdm-claim"
]
},
"text" : {
"status" : "extensions",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p><b>Generated Narrative: Claim</b><a name=\"CDMClaimProfessionalInstance\"> </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 \"CDMClaimProfessionalInstance\" </p><p style=\"margin-bottom: 0px\">Information Source: http://acme-health.com/WellnessMedicalCenter!</p><p style=\"margin-bottom: 0px\">Profile: <a href=\"StructureDefinition-cdm-claim.html\">CDM Claim</a></p></div><p><b>Snapshot Age In Years</b>: 20</p><p><b>Aggregate Claim Indicator</b>: N</p><p><b>Claim Snapshot Provider Name</b>: Dr Smith</p><p><b>Claim Snapshot Provider Zip Code</b>: 79912</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>Employer</b>: EmployerCode <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (local-employer-code#EmployerCode)</span></p><p><b>Financial System</b>: FinanceSys <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (local-financial-system#FinanceSys)</span></p><p><b>Claim Category</b>: F1 <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (claim-status-category-codes#F1)</span></p><p><b>Claim Status</b>: F1 <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (claim-status-codes#F1)</span></p><p><b>Last Claim Indicator</b>: Y</p><p><b>Participating Plan</b>: LocalParticipatingPlan <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (local-participating-plan#LocalParticipatingPlan)</span></p><p><b>Referral Indicator</b>: N</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>: Y</p><p><b>identifier</b>: Source System Row Identifier: 000000000000000000019721078(use: OFFICIAL), Source System Row Identifier: 000000000000000000099999999(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>created</b>: 2017-07-15 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=\"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><h3>SupportingInfos</h3><table class=\"grid\"><tr><td>-</td><td><b>Sequence</b></td><td><b>Category</b></td><td><b>Code</b></td><td><b>Value[x]</b></td></tr><tr><td>*</td><td>1</td><td>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></td><td>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></td><td>Y</td></tr></table><blockquote><p><b>diagnosis</b></p><p><b>sequence</b>: 1</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>: 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></blockquote><blockquote><p><b>diagnosis</b></p><p><b>sequence</b>: 2</p><p><b>diagnosis</b>: Encntr for general adult medical exam w/o abnormal findings <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>#Z00.00)</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></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-PrimaryPayerExample.html\">Coverage/PrimaryPayerExample</a></td><td>Y</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>2017-06-25</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>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><td><b>BodySite</b></td><td><b>SubSite</b></td></tr><tr><td>*</td><td>, , , </td><td>1</td><td>2</td><td>Annual wellness visit; includes a personalized prevention plan of service (pps), initial visit <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (2.16.840.1.113883.6.285#G0438; local-service-type#LocalServiceType)</span></td><td>Dressing for one wound <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-procedure-modifier.html\">Procedure Modifier Codes</a>#A1)</span></td><td>2017-06-25 --> 2017-06-25</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>1</td><td>Upper Right Third Molar (Wisdom Tooth) <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-ada-tooth.html\">American Dental Association Tooth Numbering Code System</a>#1; <a href=\"CodeSystem-ada-tooth-quadrant.html\">American Dental Association Tooth Quadrant Code System</a>#UR)</span></td><td>LocalToothSurface1 <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (local-tooth-surface#LocalToothSurface1)</span>, LocalToothSurface2 <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (local-tooth-surface#LocalToothSurface2)</span></td></tr></table></div>"
},
"extension" : [
{
"url" : "http://linuxforhealth.org/fhir/cdm/StructureDefinition/snapshot-age-in-years",
"valueUnsignedInt" : 20
},
{
"url" : "http://linuxforhealth.org/fhir/cdm/StructureDefinition/aggregate-claim-indicator",
"valueString" : "N"
},
{
"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/employee-business-unit",
"valueCodeableConcept" : {
"coding" : [
{
"system" : "http://acme-health.com/CodeSystem/local-employee-business-unit",
"code" : "EmpBusUnit"
}
]
}
},
{
"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/financial-system",
"valueCodeableConcept" : {
"coding" : [
{
"system" : "http://acme-health.com/CodeSystem/local-financial-system",
"code" : "FinanceSys"
}
]
}
},
{
"url" : "http://linuxforhealth.org/fhir/cdm/StructureDefinition/claim-category",
"valueCodeableConcept" : {
"coding" : [
{
"system" : "https://x12.org/codes/claim-status-category-codes",
"code" : "F1"
}
]
}
},
{
"url" : "http://linuxforhealth.org/fhir/cdm/StructureDefinition/claim-status",
"valueCodeableConcept" : {
"coding" : [
{
"system" : "https://x12.org/codes/claim-status-codes",
"code" : "F1"
}
]
}
},
{
"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" : "LocalParticipatingPlan"
}
]
}
},
{
"url" : "http://linuxforhealth.org/fhir/cdm/StructureDefinition/referral-indicator",
"valueString" : "N"
},
{
"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" : "Y"
}
],
"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 Center"
}
},
{
"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" : "000000000000000000099999999"
}
],
"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"
},
"created" : "2017-07-15T17:31:00-05:00",
"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" : "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" : "network-provider-indicator"
}
]
},
"valueString" : "Y"
}
],
"diagnosis" : [
{
"sequence" : 1,
"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" : "principal"
}
]
}
]
},
{
"sequence" : 2,
"diagnosisCodeableConcept" : {
"coding" : [
{
"system" : "http://hl7.org/fhir/sid/icd-10-cm",
"code" : "Z00.00",
"display" : "Encntr for general adult medical exam w/o abnormal findings"
}
]
},
"type" : [
{
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/ex-diagnosistype",
"code" : "discharge"
}
]
}
]
}
],
"insurance" : [
{
"extension" : [
{
"url" : "http://linuxforhealth.org/fhir/cdm/StructureDefinition/crossover-indicator",
"valueString" : "N"
},
{
"url" : "http://linuxforhealth.org/fhir/cdm/StructureDefinition/line-of-business",
"valueCodeableConcept" : {
"coding" : [
{
"system" : "http://acme-health.com/CodeSystem/local-line-of-business",
"code" : "LocalLineOfBusiness"
}
]
}
},
{
"url" : "http://linuxforhealth.org/fhir/cdm/StructureDefinition/prior-authorization-indicator",
"valueString" : "Y"
}
],
"sequence" : 1,
"focal" : true,
"identifier" : {
"system" : "http://acme-health.com/INSABC",
"value" : "PPOB"
},
"coverage" : {
"reference" : "Coverage/PrimaryPayerExample"
},
"preAuthRef" : [
"Y"
]
}
],
"accident" : {
"date" : "2017-06-25",
"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
],
"productOrService" : {
"coding" : [
{
"system" : "https://oidref.com/2.16.840.1.113883.6.285",
"code" : "G0438"
},
{
"system" : "http://acme-health.com/CodeSystem/local-service-type",
"code" : "LocalServiceType"
}
],
"text" : "Annual wellness visit; includes a personalized prevention plan of service (pps), initial visit"
},
"modifier" : [
{
"coding" : [
{
"system" : "http://linuxforhealth.org/fhir/cdm/CodeSystem/procedure-modifier",
"code" : "A1"
}
]
}
],
"servicedPeriod" : {
"start" : "2017-06-25",
"end" : "2017-06-25"
},
"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" : 1
}
}
],
"value" : 1
},
"bodySite" : {
"coding" : [
{
"system" : "http://linuxforhealth.org/fhir/cdm/CodeSystem/ada-tooth",
"code" : "1"
},
{
"system" : "http://linuxforhealth.org/fhir/cdm/CodeSystem/ada-tooth-quadrant",
"code" : "UR"
}
]
},
"subSite" : [
{
"coding" : [
{
"system" : "http://acme-health.com/CodeSystem/local-tooth-surface",
"code" : "LocalToothSurface1"
}
]
},
{
"coding" : [
{
"system" : "http://acme-health.com/CodeSystem/local-tooth-surface",
"code" : "LocalToothSurface2"
}
]
}
]
}
]
}
IG © 2021+ LinuxForHealth Team. Package linuxforhealth.fhir.ig#8.0.0 based on FHIR 4.0.1. Generated 2022-11-10
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