Bundle ClaimResponseBundle-example-01 of type collection

Entry 1 - fullUrl = ClaimResponse/example-01

Resource ClaimResponse:

Generated Narrative: ClaimResponse

Resource ClaimResponse "example-01"

Profile: ClaimResponse

status: ACTIVE

type: Oral (Claim Type Codes#oral)

use: PREAUTHORIZATION

patient: See above (Patient/Patient-example-01)

created: 2022-12-20 15:32:26+0530

insurer: See above (Organization/Organization-example-01)

requestor: See above (Organization/Organization-example-01)

request: See above (Claim/preauth-example-01)

outcome: COMPLETE

disposition: The enclosed services are authorized for your provision within 30 days of this notice.

preAuthRef: 18SS12345

payeeType: Provider (Claim Payee Type Codes#provider)

addItem

itemSequence: 1

productOrService: Dengue (SNOMED CT#38362002)

programCode: Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (AB-PMJAY) (Program Code#AB-PMJAY)

Nets

-	Value	Currency
*	25000	INR

adjudication

addItem

itemSequence: 2

productOrService: Chronic diarrhea (SNOMED CT#236071009)

programCode: Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (AB-PMJAY) (Program Code#AB-PMJAY)

Nets

-	Value	Currency
*	15000	INR

adjudication

ProcessNotes

-	Number	Type	Text	Language
*	101	Print (Form) (NoteType#print)	Please submit a Pre-Authorization request if a more extensive examination or urgent services are required.	English (Region=India) (Tags for the Identification of Languages#en-IN)

Insurances

-	Sequence	Focal	Coverage
*	1	true	See above (Coverage/Coverage-example-01)

Entry 2 - fullUrl = Patient/Patient-example-01

Resource Patient:

Ayush Sharma Male, DoB: 1981-01-12 ( Adhaar number: 7225-4829-5255)

Entry 3 - fullUrl = Organization/Organization-example-01

Resource Organization:

Generated Narrative: Organization

Resource Organization "Organization-example-01"

Profile: Organization

identifier: Provider number: 4567878

name: Appolo Hospital

Contacts

-	Telecom
*	+91 243 2634 1234, contact@xyz.org

Entry 4 - fullUrl = Organization/Organization-example-02

Resource Organization:

Generated Narrative: Organization

Resource Organization "Organization-example-02"

Profile: Organization

identifier: Provider number: 555511

name: Star Health Corporation.

Contacts

-	Telecom
*	+91 555 2634 888, contact@xyz.org

Entry 5 - fullUrl = Claim/preauth-example-01

Resource Claim:

Generated Narrative: Claim

Resource Claim "preauth-example-01"

Profile: Claim

identifier: id: 7612345

status: ACTIVE

type: Professional (Claim Type Codes#professional)

use: PREAUTHORIZATION

patient: Patient/example-01 ""

created: 2022-07-20 11:01:00+0500

insurer: See above (Organization/Organization-example-02)

provider: See above (Organization/Organization-example-02)

priority: Normal (Process Priority Codes#normal)

SupportingInfos

-	Sequence	Category	Code	Value[x]
*	1	proof of identity (SupportingInfo Category#POI)	Adhaar number (Identifier Type Code#ADN)	DocumentReference/example-01

diagnosis

sequence: 1

diagnosis: Condition/example-01

type: Clinical Diagnosis (Example Diagnosis Type Codes#clinical)

diagnosis

sequence: 2

diagnosis: See above (Condition/Condition-example-02)

type: Clinical Diagnosis (Example Diagnosis Type Codes#clinical)

Insurances

-	Sequence	Focal	Coverage	PreAuthRef
*	1	true	Coverage/example-01	12S52

item

sequence: 1

category: Medical care (SNOMED CT#781087000)

productOrService: Dengue (SNOMED CT#38362002)

programCode: Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (AB-PMJAY) (Program Code#AB-PMJAY)

UnitPrices

-	Value	Currency
*	25000	INR

item

sequence: 2

category: Medical care (SNOMED CT#781087000)

productOrService: Chronic diarrhea (SNOMED CT#236071009)

programCode: Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (AB-PMJAY) (Program Code#AB-PMJAY)

UnitPrices

-	Value	Currency
*	15000	INR

Entry 6 - fullUrl = Coverage/Coverage-example-01

Resource Coverage:

Generated Narrative: Coverage

Resource Coverage "Coverage-example-01"

identifier: id: SP12345678

status: ACTIVE

type: PAY (Coverage SelfPay Codes#pay)

subscriber: Patient/example-01 ""

beneficiary: Patient/example-01 ""

relationship: Self (SubscriberPolicyholder Relationship Codes#self)

period: 2022-12-01 --> 2025-03-17

Entry 7 - fullUrl = Condition/Condition-example-01

Resource Condition:

Generated Narrative: Condition

Resource Condition "Condition-example-01"

code: Dengue (disorder) (SNOMED CT#38362002)

subject: Patient/example-01 ""

Entry 8 - fullUrl = Condition/Condition-example-02

Resource Condition:

Generated Narrative: Condition

Resource Condition "Condition-example-02"

code: Chronic diarrhea of unknown origin (disorder) (SNOMED CT#17551007)

subject: Patient/example-01 ""