FHIR Implementation Guide for ABDM
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FHIR Implementation Guide for ABDM - Local Development build (v4.0.0). See the Directory of published versions

: ClaimResponse/preauth-example-01 - XML Representation

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<ClaimResponse xmlns="http://hl7.org/fhir">
  <id value="preauth-example-01"/>
  <meta>
    <profile
             value="https://nrces.in/ndhm/fhir/r4/StructureDefinition/ClaimResponse"/>
  </meta>
  <text>
    <status value="generated"/>
    <div xmlns="http://www.w3.org/1999/xhtml"><p><b>Generated Narrative: ClaimResponse</b><a name="preauth-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 ClaimResponse &quot;preauth-example-01&quot; </p><p style="margin-bottom: 0px">Profile: <a href="StructureDefinition-ClaimResponse.html">ClaimResponse</a></p></div><p><b>status</b>: active</p><p><b>type</b>: Management of health status after discharge from hospital (procedure) <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="https://browser.ihtsdotools.org/">SNOMED CT</a>#710967003)</span></p><p><b>subType</b>: Emergency Claim <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="http://terminology.hl7.org/5.3.0/CodeSystem-ex-claimsubtype.html">Example Claim SubType Codes</a>#emergency)</span></p><p><b>use</b>: preauthorization</p><p><b>patient</b>: <a href="Patient-example-01.html">Patient/example-01</a> &quot;&quot;</p><p><b>created</b>: 2023-09-07 15:32:26+0530</p><p><b>insurer</b>: <a href="Organization-example-02.html">Organization/example-02</a> &quot;XYZ Insurance Co. Ltd.&quot;</p><p><b>requestor</b>: <a href="Practitioner-example-01.html">Practitioner/example-01</a> &quot;&quot;</p><p><b>request</b>: <a href="Claim-preauth-example-01.html">Claim/preauth-example-01</a></p><p><b>outcome</b>: complete</p><p><b>disposition</b>: The enclosed services are authorized for your provision within 30 days of this notice.</p><p><b>preAuthRef</b>: 12S52</p><p><b>payeeType</b>: Provider <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="http://terminology.hl7.org/5.3.0/CodeSystem-payeetype.html">Payee Type Codes</a>#provider)</span></p><blockquote><p><b>addItem</b></p><p><b>itemSequence</b>: 1</p><p><b>productOrService</b>: Consultant <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="https://browser.ihtsdotools.org/">SNOMED CT</a>#768839008)</span></p><h3>Nets</h3><table class="grid"><tr><td style="display: none">-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td style="display: none">*</td><td>500.00</td><td>INR</td></tr></table><blockquote><p><b>adjudication</b></p><p><b>category</b>: Eligible Amount <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="http://terminology.hl7.org/5.3.0/CodeSystem-adjudication.html">Adjudication Value Codes</a>#eligible)</span></p><p><b>reason</b>: Covered <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="https://browser.ihtsdotools.org/">SNOMED CT</a>#255334000)</span></p><blockquote><p><b>amount</b></p><p><span title="Indian Rupee">₹500.00</span> (INR)</p></blockquote></blockquote></blockquote><blockquote><p><b>addItem</b></p><p><b>itemSequence</b>: 2</p><p><b>productOrService</b>: Metformin hydrochloride 500 mg prolonged-release oral tablet <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="https://browser.ihtsdotools.org/">SNOMED CT</a>#765507008)</span></p><h3>Nets</h3><table class="grid"><tr><td style="display: none">-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td style="display: none">*</td><td>910.28</td><td>INR</td></tr></table><blockquote><p><b>adjudication</b></p><p><b>category</b>: Eligible Amount <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="http://terminology.hl7.org/5.3.0/CodeSystem-adjudication.html">Adjudication Value Codes</a>#eligible)</span></p><p><b>reason</b>: Covered <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="https://browser.ihtsdotools.org/">SNOMED CT</a>#255334000)</span></p><blockquote><p><b>amount</b></p><p><span title="Indian Rupee">₹910.28</span> (INR)</p></blockquote></blockquote></blockquote><blockquote><p><b>total</b></p><p><b>category</b>: Submitted Amount <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="http://terminology.hl7.org/5.3.0/CodeSystem-adjudication.html">Adjudication Value Codes</a>#submitted)</span></p><h3>Amounts</h3><table class="grid"><tr><td style="display: none">-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td style="display: none">*</td><td>1410.28</td><td>INR</td></tr></table></blockquote><h3>Insurances</h3><table class="grid"><tr><td style="display: none">-</td><td><b>Sequence</b></td><td><b>Focal</b></td><td><b>Coverage</b></td></tr><tr><td style="display: none">*</td><td>1</td><td>true</td><td><a href="Coverage-example-01.html">Coverage/example-01</a></td></tr></table></div>
  </text>
  <status value="active"/>
  <type>
    <coding>
      <system value="http://snomed.info/sct"/>
      <code value="710967003"/>
      <display
               value="Management of health status after discharge from hospital (procedure)"/>
    </coding>
  </type>
  <subType>
    <coding>
      <system value="http://terminology.hl7.org/CodeSystem/ex-claimsubtype"/>
      <code value="emergency"/>
    </coding>
  </subType>
  <use value="preauthorization"/>
  <patient>
    <reference value="Patient/example-01"/>
  </patient>
  <created value="2023-09-07T15:32:26.605+05:30"/>
  <insurer>
    <reference value="Organization/example-02"/>
  </insurer>
  <requestor>
    <reference value="Practitioner/example-01"/>
  </requestor>
  <request>
    <reference value="Claim/preauth-example-01"/>
  </request>
  <outcome value="complete"/>
  <disposition
               value="The enclosed services are authorized for your provision within 30 days of this notice."/>
  <preAuthRef value="12S52"/>
  <payeeType>
    <coding>
      <system value="http://terminology.hl7.org/CodeSystem/payeetype"/>
      <code value="provider"/>
    </coding>
  </payeeType>
  <addItem>
    <itemSequence value="1"/>
    <productOrService>
      <coding>
        <system value="http://snomed.info/sct"/>
        <code value="768839008"/>
        <display value="Consultant"/>
      </coding>
    </productOrService>
    <net>
      <value value="500.00"/>
      <currency value="INR"/>
    </net>
    <adjudication>
      <category>
        <coding>
          <system value="http://terminology.hl7.org/CodeSystem/adjudication"/>
          <code value="eligible"/>
          <display value="Eligible Amount"/>
        </coding>
      </category>
      <reason>
        <coding>
          <system value="http://snomed.info/sct"/>
          <code value="255334000"/>
          <display value="Covered"/>
        </coding>
      </reason>
      <amount>
        <value value="500"/>
        <currency value="INR"/>
      </amount>
    </adjudication>
  </addItem>
  <addItem>
    <itemSequence value="2"/>
    <productOrService>
      <coding>
        <system value="http://snomed.info/sct"/>
        <code value="765507008"/>
        <display
                 value="Metformin hydrochloride 500 mg prolonged-release oral tablet"/>
      </coding>
    </productOrService>
    <net>
      <value value="910.28"/>
      <currency value="INR"/>
    </net>
    <adjudication>
      <category>
        <coding>
          <system value="http://terminology.hl7.org/CodeSystem/adjudication"/>
          <code value="eligible"/>
          <display value="Eligible Amount"/>
        </coding>
      </category>
      <reason>
        <coding>
          <system value="http://snomed.info/sct"/>
          <code value="255334000"/>
          <display value="Covered"/>
        </coding>
      </reason>
      <amount>
        <value value="910.28"/>
        <currency value="INR"/>
      </amount>
    </adjudication>
  </addItem>
  <total>
    <category>
      <coding>
        <system value="http://terminology.hl7.org/CodeSystem/adjudication"/>
        <code value="submitted"/>
      </coding>
    </category>
    <amount>
      <value value="1410.28"/>
      <currency value="INR"/>
    </amount>
  </total>
  <insurance>
    <sequence value="1"/>
    <focal value="true"/>
    <coverage>
      <reference value="Coverage/example-01"/>
    </coverage>
  </insurance>
</ClaimResponse>