LinuxForHealth FHIR Implementation Guide
8.0.0 - draft
LinuxForHealth FHIR Implementation Guide - Local Development build (v8.0.0). See the Directory of published versions
<Claim xmlns="http://hl7.org/fhir">
<id value="CDMClaimProfessionalInstance"/>
<meta>
<extension
url="http://linuxforhealth.org/fhir/cdm/StructureDefinition/tenant-id">
<valueString value="tenant7209"/>
</extension>
<extension
url="http://linuxforhealth.org/fhir/cdm/StructureDefinition/ingestion-batch-id">
<valueString value="rgVCJnQBxvghkKTI8Hzz"/>
</extension>
<extension
url="http://linuxforhealth.org/fhir/cdm/StructureDefinition/process-name">
<valueString value="TREX"/>
</extension>
<extension
url="http://linuxforhealth.org/fhir/cdm/StructureDefinition/process-client-id">
<valueString value="7209"/>
</extension>
<extension
url="http://linuxforhealth.org/fhir/cdm/StructureDefinition/process-record-id">
<valueIdentifier>
<system value="http://acme-health.com/WellnessMedicalCenter"/>
<value value="7209_07869_e00080779_3938586_2516181"/>
</valueIdentifier>
</extension>
<extension
url="http://linuxforhealth.org/fhir/cdm/StructureDefinition/source-file-id">
<valueString value="e00080779"/>
</extension>
<source value="http://acme-health.com/WellnessMedicalCenter"/>
<profile
value="http://linuxforhealth.org/fhir/cdm/StructureDefinition/cdm-claim"/>
</meta>
<text>
<status value="extensions"/>
<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>
</text>
<extension
url="http://linuxforhealth.org/fhir/cdm/StructureDefinition/snapshot-age-in-years">
<valueUnsignedInt value="20"/>
</extension>
<extension
url="http://linuxforhealth.org/fhir/cdm/StructureDefinition/aggregate-claim-indicator">
<valueString value="N"/>
</extension>
<extension
url="http://linuxforhealth.org/fhir/cdm/StructureDefinition/claim-snapshot-provider-name">
<valueString value="Dr Smith"/>
</extension>
<extension
url="http://linuxforhealth.org/fhir/cdm/StructureDefinition/claim-snapshot-provider-zip-code">
<valueString value="79912"/>
</extension>
<extension
url="http://linuxforhealth.org/fhir/cdm/StructureDefinition/employee-business-unit">
<valueCodeableConcept>
<coding>
<system
value="http://acme-health.com/CodeSystem/local-employee-business-unit"/>
<code value="EmpBusUnit"/>
</coding>
</valueCodeableConcept>
</extension>
<extension
url="http://linuxforhealth.org/fhir/cdm/StructureDefinition/employer">
<valueCodeableConcept>
<coding>
<system
value="http://acme-health.com/CodeSystem/local-employer-code"/>
<code value="EmployerCode"/>
</coding>
</valueCodeableConcept>
</extension>
<extension
url="http://linuxforhealth.org/fhir/cdm/StructureDefinition/financial-system">
<valueCodeableConcept>
<coding>
<system
value="http://acme-health.com/CodeSystem/local-financial-system"/>
<code value="FinanceSys"/>
</coding>
</valueCodeableConcept>
</extension>
<extension
url="http://linuxforhealth.org/fhir/cdm/StructureDefinition/claim-category">
<valueCodeableConcept>
<coding>
<system value="https://x12.org/codes/claim-status-category-codes"/>
<code value="F1"/>
</coding>
</valueCodeableConcept>
</extension>
<extension
url="http://linuxforhealth.org/fhir/cdm/StructureDefinition/claim-status">
<valueCodeableConcept>
<coding>
<system value="https://x12.org/codes/claim-status-codes"/>
<code value="F1"/>
</coding>
</valueCodeableConcept>
</extension>
<extension
url="http://linuxforhealth.org/fhir/cdm/StructureDefinition/last-claim-indicator">
<valueString value="Y"/>
</extension>
<extension
url="http://linuxforhealth.org/fhir/cdm/StructureDefinition/participating-plan">
<valueCodeableConcept>
<coding>
<system
value="http://acme-health.com/CodeSystem/local-participating-plan"/>
<code value="LocalParticipatingPlan"/>
</coding>
</valueCodeableConcept>
</extension>
<extension
url="http://linuxforhealth.org/fhir/cdm/StructureDefinition/referral-indicator">
<valueString value="N"/>
</extension>
<extension
url="http://linuxforhealth.org/fhir/cdm/StructureDefinition/submission-type">
<valueCodeableConcept>
<coding>
<system
value="http://acme-health.com/CodeSystem/local-submission-type"/>
<code value="SubmitType"/>
</coding>
</valueCodeableConcept>
</extension>
<extension
url="http://linuxforhealth.org/fhir/cdm/StructureDefinition/payer-pcp-responsibility-indicator">
<valueString value="Y"/>
</extension>
<identifier>
<use value="official"/>
<type>
<coding>
<system
value="http://linuxforhealth.org/fhir/cdm/CodeSystem/identifier-type"/>
<code value="SSRI"/>
</coding>
</type>
<system value="http://acme-health.com/CodeSystem/local-claim-identifier"/>
<value value="000000000000000000019721078"/>
<assigner>
<display value="Acme Health - Wellness Medical Center"/>
</assigner>
</identifier>
<identifier>
<use value="secondary"/>
<type>
<coding>
<system
value="http://linuxforhealth.org/fhir/cdm/CodeSystem/identifier-type"/>
<code value="SSRI"/>
</coding>
</type>
<system
value="http://acme-health.com/CodeSystem/local-authorization-identifier"/>
<value value="000000000000000000099999999"/>
</identifier>
<status value="active"/>
<type>
<coding>
<system
value="http://linuxforhealth.org/fhir/cdm/CodeSystem/payer-claim-type"/>
<code value="medical"/>
</coding>
<coding>
<system value="http://acme-health.com/CodeSystem/local-claim-type"/>
<code value="Medical"/>
</coding>
</type>
<subType>
<coding>
<system
value="http://linuxforhealth.org/fhir/cdm/CodeSystem/claim-subtype"/>
<code value="emergency"/>
</coding>
</subType>
<use value="claim"/>
<patient>
<reference value="Patient/CDMPatientInstance"/>
</patient>
<created value="2017-07-15T17:31:00-05:00"/>
<provider>
<reference value="Organization/Provider1"/>
</provider>
<priority>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/processpriority"/>
<code value="normal"/>
</coding>
</priority>
<referral>
<reference value="ServiceRequest/CDMServiceRequestInstance"/>
</referral>
<careTeam>
<sequence value="1"/>
<provider>
<reference value="Practitioner/DrKelly"/>
</provider>
<role>
<coding>
<system
value="http://linuxforhealth.org/fhir/cdm/CodeSystem/claim-care-team-role"/>
<code value="ordering"/>
</coding>
</role>
</careTeam>
<careTeam>
<sequence value="2"/>
<provider>
<reference value="Organization/Provider1"/>
</provider>
<role>
<coding>
<system
value="http://linuxforhealth.org/fhir/cdm/CodeSystem/claim-care-team-role"/>
<code value="servicing"/>
</coding>
</role>
<qualification>
<coding>
<system value="http://acme-health.com/CodeSystem/local-specialty"/>
<code value="01"/>
</coding>
</qualification>
</careTeam>
<supportingInfo>
<sequence value="1"/>
<category>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/claiminformationcategory"/>
<code value="info"/>
</coding>
</category>
<code>
<coding>
<system
value="http://linuxforhealth.org/fhir/cdm/CodeSystem/claim-supporting-info-type"/>
<code value="network-provider-indicator"/>
</coding>
</code>
<valueString value="Y"/>
</supportingInfo>
<diagnosis>
<sequence value="1"/>
<diagnosisCodeableConcept>
<coding>
<system value="http://hl7.org/fhir/sid/icd-10-cm"/>
<code value="G43.909"/>
<display
value="Migraine, Unspecified, not Intractable, without Status Migrainosus"/>
</coding>
</diagnosisCodeableConcept>
<type>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/ex-diagnosistype"/>
<code value="principal"/>
</coding>
</type>
</diagnosis>
<diagnosis>
<sequence value="2"/>
<diagnosisCodeableConcept>
<coding>
<system value="http://hl7.org/fhir/sid/icd-10-cm"/>
<code value="Z00.00"/>
<display
value="Encntr for general adult medical exam w/o abnormal findings"/>
</coding>
</diagnosisCodeableConcept>
<type>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/ex-diagnosistype"/>
<code value="discharge"/>
</coding>
</type>
</diagnosis>
<insurance>
<extension
url="http://linuxforhealth.org/fhir/cdm/StructureDefinition/crossover-indicator">
<valueString value="N"/>
</extension>
<extension
url="http://linuxforhealth.org/fhir/cdm/StructureDefinition/line-of-business">
<valueCodeableConcept>
<coding>
<system
value="http://acme-health.com/CodeSystem/local-line-of-business"/>
<code value="LocalLineOfBusiness"/>
</coding>
</valueCodeableConcept>
</extension>
<extension
url="http://linuxforhealth.org/fhir/cdm/StructureDefinition/prior-authorization-indicator">
<valueString value="Y"/>
</extension>
<sequence value="1"/>
<focal value="true"/>
<identifier>
<system value="http://acme-health.com/INSABC"/>
<value value="PPOB"/>
</identifier>
<coverage>
<reference value="Coverage/PrimaryPayerExample"/>
</coverage>
<preAuthRef value="Y"/>
</insurance>
<accident>
<date value="2017-06-25"/>
<type>
<coding>
<system
value="http://linuxforhealth.org/fhir/cdm/CodeSystem/payer-indicators"/>
<code value="N"/>
</coding>
</type>
</accident>
<item>
<extension
url="http://linuxforhealth.org/fhir/cdm/StructureDefinition/capitated-service-indicator">
<valueString value="N"/>
</extension>
<extension
url="http://linuxforhealth.org/fhir/cdm/StructureDefinition/fully-insured-indicator">
<valueString value="Y"/>
</extension>
<extension
url="http://linuxforhealth.org/fhir/cdm/StructureDefinition/nursing-home-indicator">
<valueString value="N"/>
</extension>
<extension
url="http://linuxforhealth.org/fhir/cdm/StructureDefinition/service-bill-days-count">
<valueUnsignedInt value="20"/>
</extension>
<sequence value="1"/>
<careTeamSequence value="2"/>
<productOrService>
<coding>
<system value="https://oidref.com/2.16.840.1.113883.6.285"/>
<code value="G0438"/>
</coding>
<coding>
<system value="http://acme-health.com/CodeSystem/local-service-type"/>
<code value="LocalServiceType"/>
</coding>
<text
value="Annual wellness visit; includes a personalized prevention plan of service (pps), initial visit"/>
</productOrService>
<modifier>
<coding>
<system
value="http://linuxforhealth.org/fhir/cdm/CodeSystem/procedure-modifier"/>
<code value="A1"/>
</coding>
</modifier>
<servicedPeriod>
<start value="2017-06-25"/>
<end value="2017-06-25"/>
</servicedPeriod>
<locationCodeableConcept>
<coding>
<system
value="https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set"/>
<code value="11"/>
<display value="Office"/>
</coding>
<coding>
<system
value="http://acme-health.com/CodeSystem/local-place-of-service"/>
<code value="LocalPlcOfService"/>
</coding>
</locationCodeableConcept>
<quantity>
<extension
url="http://linuxforhealth.org/fhir/cdm/StructureDefinition/local-number-of-units-per-service">
<valueQuantity>
<value value="1"/>
</valueQuantity>
</extension>
<value value="1"/>
</quantity>
<bodySite>
<coding>
<system
value="http://linuxforhealth.org/fhir/cdm/CodeSystem/ada-tooth"/>
<code value="1"/>
</coding>
<coding>
<system
value="http://linuxforhealth.org/fhir/cdm/CodeSystem/ada-tooth-quadrant"/>
<code value="UR"/>
</coding>
</bodySite>
<subSite>
<coding>
<system
value="http://acme-health.com/CodeSystem/local-tooth-surface"/>
<code value="LocalToothSurface1"/>
</coding>
</subSite>
<subSite>
<coding>
<system
value="http://acme-health.com/CodeSystem/local-tooth-surface"/>
<code value="LocalToothSurface2"/>
</coding>
</subSite>
</item>
</Claim>
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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