ClaimResponseBundle-enhancement-example-01 - FHIR Implementation Guide for ABDM v5.0.0

FHIR Implementation Guide for ABDM - Local Development build (v5.0.0). See the Directory of published versions

Example Bundle: ClaimResponseBundle-enhancement-example-01

Bundle ClaimResponseBundle-enhancement-example-01 of type collection

Entry 1 - fullUrl = ClaimResponse/ClaimResponse-enhancement-example-01

Resource ClaimResponse:

Generated Narrative: ClaimResponse
Resource ClaimResponse "ClaimResponse-enhancement-example-01"
Profile: ClaimResponse
status: ACTIVE
type: Inpatient care management (procedure) (SNOMED CT#737481003)
subType: Emergency Claim (Example Claim SubType Codes#emergency)
use: PREAUTHORIZATION
patient: See above (Patient/Patient-example-01)
created: 2023-12-12 15:32:26+0530
insurer: See above (Organization/Organization-example-01)
requestor: See above (Organization/Organization-example-02)
request: See above (Claim/Claim-enhancement-example-01)
outcome: COMPLETE
disposition: The enclosed services are authorized for your provision within 30 days of this notice.
preAuthRef: 123456
payeeType: Provider (Payee Type Codes#provider)
addItem
itemSequence: 1
productOrService: Angiography (SNOMED CT#77343006)
Nets
- Value Currency
* 10000.00 INR
adjudication
addItem
itemSequence: 2
productOrService: Angioplasty of blood vessel (SNOMED CT#418285008)
Nets
- Value Currency
* 10000 INR
adjudication
total
category: Submitted Amount (Adjudication Value Codes#submitted)
Amounts
- Value Currency
* 20000 INR
Insurances
- Sequence Focal Coverage
* 1 true See above (Coverage/Coverage-example-01)

Entry 2 - fullUrl = Claim/Claim-enhancement-example-01

Resource Claim:

Generated Narrative: Claim
Resource Claim "Claim-enhancement-example-01"
Profile: Claim
identifier: id: 7612345
status: ACTIVE
type: Inpatient care management (procedure) (SNOMED CT#737481003)
subType: Emergency Claim (Example Claim SubType Codes#emergency)
use: PREAUTHORIZATION
patient: See above (Patient/Patient-example-01)
billablePeriod: 2023-12-09 11:01:00+0500 --> 2023-12-30 11:01:00+0500
created: 2023-12-13 11:01:00+0500
insurer: See above (Organization/Organization-example-01)
provider: See above (Organization/Organization-example-02)
priority: Normal (Process Priority Codes#normal)
Relateds
- Claim Relationship
* See above (Claim/Claim-preauth-example-01) Enhancement (Related Claim Relationship Code#enhancement)
CareTeams
- Sequence Provider Role
* 1 See above (Practitioner/Practitioner-example-01) Healthcare professional (occupation) (SNOMED CT#223366009)
SupportingInfos
- Sequence Category Code Value[x]
* 1 Document Type - Investigation (SupportingInfo Category#INV) Angiography (SNOMED CT#77343006) See above (DocumentReference/DocumentReference-example-02)
Diagnoses
- Sequence Diagnosis[x] Type
* 1 Cardiac arrest, unspecified (ICD-10#I46.9) Final diagnosis (discharge) (contextual qualifier) (qualifier value) (SNOMED CT#89100005)
procedure
sequence: 1
procedure: Angiography (SNOMED CT#77343006)
procedure
sequence: 2
procedure: Angioplasty of blood vessel (SNOMED CT#418285008)
Insurances
- Sequence Focal Coverage PreAuthRef
* 1 true See above (Coverage/Coverage-example-01) 123456
item
sequence: 1
careTeamSequence: 1
productOrService: Angiography (SNOMED CT#77343006)
serviced: 2023-12-09
UnitPrices
- Value Currency
* 10000.00 INR
Nets
- Value Currency
* 10000.00 INR
item
sequence: 2
careTeamSequence: 1
productOrService: Angioplasty of blood vessel (SNOMED CT#418285008)
UnitPrices
- Value Currency
* 10000 INR
Nets
- Value Currency
* 10000 INR
Totals
- Value Currency
* 20000 INR

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

Resource Patient:

Adarsh Agrawal Male, DoB: 1981-01-12 ( Adhaar number: 7225-4829-5255)

Entry 4 - fullUrl = Organization/Organization-example-01

Resource Organization:

Generated Narrative: Organization
Resource Organization "Organization-example-01"
Profile: Organization
identifier: Provider number: 4567878
type: Insurance Company (Organization type#ins)
name: XYZ Insurance Co. Ltd.
Contacts
- Telecom
* +91 243 2634 1234, contact@xyz.org

Entry 5 - fullUrl = Organization/Organization-example-02

Resource Organization:

Generated Narrative: Organization
Resource Organization "Organization-example-02"
Profile: Organization
identifier: Provider number: 45675454
type: Healthcare Provider (Organization type#prov)
name: XYZ Hospital Co. Ltd.
Contacts
- Telecom
* +91 243 2634 1278, contact@xyz.org

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

Resource Practitioner:

Generated Narrative: Practitioner
Resource Practitioner "Practitioner-example-01" Version "1" Updated "2023-09-07 14:58:58+0530"
Profile: Practitioner
identifier: Medical License number: 21-1521-3828-3227
name: Dr. Aayush Agrawal

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

Resource Coverage:

Generated Narrative: Coverage
Resource Coverage "Coverage-example-01"
Profile: Coverage
identifier: id: 235037120
status: ACTIVE
type: PAY (Coverage SelfPay Codes#pay)
subscriber: See above (Patient/Patient-example-01)
subscriberId: id: ABC123456BI007
beneficiary: See above (Patient/Patient-example-01)
relationship: Self (SubscriberPolicyholder Relationship Codes#self)
period: ?? --> 2026-03-17

Entry 8 - fullUrl = Claim/Claim-preauth-example-01

Resource Claim:

Generated Narrative: Claim
Resource Claim "Claim-preauth-example-01"
Profile: Claim
identifier: id: 7612345
status: ACTIVE
type: Inpatient care management (procedure) (SNOMED CT#737481003)
subType: Emergency Claim (Example Claim SubType Codes#emergency)
use: PREAUTHORIZATION
patient: See above (Patient/Patient-example-01)
billablePeriod: 2023-12-09 11:01:00+0500 --> 2023-12-30 11:01:00+0500
created: 2023-12-11 11:01:00+0500
insurer: See above (Organization/Organization-example-01)
provider: See above (Organization/Organization-example-02)
priority: Normal (Process Priority Codes#normal)
prescription: See above (MedicationRequest/MedicationRequest-example-01)
CareTeams
- Sequence Provider Role
* 1 See above (Practitioner/Practitioner-example-01) Healthcare professional (occupation) (SNOMED CT#223366009)
SupportingInfos
- Sequence Category Code Value[x]
* 1 Document Type - Investigation (SupportingInfo Category#INV) Angiography (SNOMED CT#77343006) See above (DocumentReference/DocumentReference-example-01)
Diagnoses
- Sequence Diagnosis[x] Type
* 1 Cardiac arrest, unspecified (ICD-10#I46.9) Final diagnosis (discharge) (contextual qualifier) (qualifier value) (SNOMED CT#89100005)
procedure
sequence: 1
procedure: Angiography (SNOMED CT#77343006)
procedure
sequence: 2
procedure: Angioplasty of blood vessel (SNOMED CT#418285008)
Insurances
- Sequence Focal Coverage PreAuthRef
* 1 true See above (Coverage/Coverage-example-01) 123456
item
sequence: 1
careTeamSequence: 1
productOrService: Angiography (SNOMED CT#77343006)
serviced: 2023-12-09
UnitPrices
- Value Currency
* 10000.00 INR
Nets
- Value Currency
* 10000.00 INR
item
sequence: 2
careTeamSequence: 1
productOrService: Angioplasty of blood vessel (SNOMED CT#418285008)
UnitPrices
- Value Currency
* 40000 INR
Nets
- Value Currency
* 40000 INR
item
sequence: 3
careTeamSequence: 1
productOrService: Intensive care unit (SNOMED CT#309904001)
serviced: 2023-12-11
quantity: 10 day
UnitPrices
- Value Currency
* 2000 INR
Nets
- Value Currency
* 20000 INR
item
sequence: 4
careTeamSequence: 1
productOrService: Aspirin 75 mg oral tablet (SNOMED CT#319775004)
UnitPrices
- Value Currency
* 100 INR
Nets
- Value Currency
* 100 INR
Totals
- Value Currency
* 70100 INR

Entry 9 - fullUrl = MedicationRequest/MedicationRequest-example-01

Resource MedicationRequest:

Generated Narrative: MedicationRequest
Resource MedicationRequest "MedicationRequest-example-01"
Profile: MedicationRequest
status: ACTIVE
intent: ORDER
subject: See above (Patient/Patient-example-01)
authoredOn: 2023-12-11
requester: See above (Practitioner/Practitioner-example-01)
DosageInstructions
- Text AdditionalInstruction Timing Route Method
* One tablet at once With or after food (SNOMED CT#311504000) Once per 1 days Oral Route (SNOMED CT#26643006) Swallow (SNOMED CT#421521009)

Entry 10 - fullUrl = Condition/Condition-example-01

Resource Condition:

Generated Narrative: Condition
Resource Condition "Condition-example-01"
Profile: Condition
code: Cardiac arrest, unspecified (ICD-10#I46.9)
subject: See above (Patient/Patient-example-01)
onset: 1days

Entry 11 - fullUrl = DocumentReference/DocumentReference-example-01

Resource DocumentReference:

Generated Narrative: DocumentReference
Resource DocumentReference "DocumentReference-example-01"
Profile: DocumentReference
status: CURRENT
docStatus: FINAL
subject: See above (Patient/Patient-example-01)
content
Attachments
- ContentType Language Data Title Creation
* application/pdf en-IN (base64 data - 80793 bytes) Adhar Card PDF 2019-05-29 14:58:58+0530

Entry 12 - fullUrl = DocumentReference/DocumentReference-example-02

Resource DocumentReference:

Generated Narrative: DocumentReference
Resource DocumentReference "DocumentReference-example-02"
Profile: DocumentReference
status: CURRENT
docStatus: FINAL
subject: See above (Patient/Patient-example-01)
content
Attachments
- ContentType Language Data Title Creation
* application/pdf en-IN (base64 data - 80793 bytes) Adhar Card PDF 2019-05-29 14:58:58+0530