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

: Claim/Claim-predetermination-example-01 - XML Representation

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<Claim xmlns="http://hl7.org/fhir">
  <id value="Claim-predetermination-example-01"/>
  <meta>
    <profile value="https://nrces.in/ndhm/fhir/r4/StructureDefinition/Claim"/>
  </meta>
  <text>
    <status value="generated"/>
    <div xmlns="http://www.w3.org/1999/xhtml"><p><b>Generated Narrative: Claim</b><a name="Claim-predetermination-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 Claim &quot;Claim-predetermination-example-01&quot; </p><p style="margin-bottom: 0px">Profile: <a href="StructureDefinition-Claim.html">Claim</a></p></div><p><b>identifier</b>: id: 7612345</p><p><b>status</b>: active</p><p><b>type</b>: Inpatient care management (procedure) <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="https://browser.ihtsdotools.org/">SNOMED CT</a>#737481003)</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>: predetermination</p><p><b>patient</b>: <a href="Patient-example-01.html">Patient/example-01</a> &quot;&quot;</p><p><b>billablePeriod</b>: 2023-12-09 11:01:00+0500 --&gt; 2023-12-30 11:01:00+0500</p><p><b>created</b>: 2023-12-11 11:01:00+0500</p><p><b>insurer</b>: <a href="Organization-example-02.html">Organization/example-02</a> &quot;XYZ Insurance Co. Ltd.&quot;</p><p><b>provider</b>: <a href="Organization-example-03.html">Organization/example-03</a> &quot;Maharashtra State Government&quot;</p><p><b>priority</b>: Normal <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="http://terminology.hl7.org/5.3.0/CodeSystem-processpriority.html">Process Priority Codes</a>#normal)</span></p><p><b>prescription</b>: <a href="MedicationRequest-example-03.html">MedicationRequest/example-03</a></p><h3>CareTeams</h3><table class="grid"><tr><td style="display: none">-</td><td><b>Sequence</b></td><td><b>Provider</b></td><td><b>Role</b></td><td><b>Qualification</b></td></tr><tr><td style="display: none">*</td><td>1</td><td><a href="Practitioner-example-01.html">Practitioner/example-01</a> &quot;&quot;</td><td>Healthcare professional (occupation) <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="https://browser.ihtsdotools.org/">SNOMED CT</a>#223366009)</span></td><td>Clinical specialty (qualifier value) <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="https://browser.ihtsdotools.org/">SNOMED CT</a>#394658006)</span></td></tr></table><h3>SupportingInfos</h3><table class="grid"><tr><td style="display: none">-</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 style="display: none">*</td><td>1</td><td>Document Type - Investigation <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="CodeSystem-ndhm-supportinginfo-category.html">SupportingInfo Category</a>#INV)</span></td><td>Angiography <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="https://browser.ihtsdotools.org/">SNOMED CT</a>#77343006)</span></td><td><a href="DocumentReference-example-03.html">DocumentReference/example-03</a></td></tr></table><h3>Diagnoses</h3><table class="grid"><tr><td style="display: none">-</td><td><b>Sequence</b></td><td><b>Diagnosis[x]</b></td><td><b>Type</b></td></tr><tr><td style="display: none">*</td><td>1</td><td>Cardiac arrest, unspecified <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="http://terminology.hl7.org/5.3.0/CodeSystem-icd10.html">ICD-10</a>#I46.9)</span></td><td>Final diagnosis (discharge) (contextual qualifier) (qualifier value) <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="https://browser.ihtsdotools.org/">SNOMED CT</a>#89100005)</span></td></tr></table><blockquote><p><b>procedure</b></p><p><b>sequence</b>: 1</p><p><b>procedure</b>: Angiography <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="https://browser.ihtsdotools.org/">SNOMED CT</a>#77343006)</span></p></blockquote><blockquote><p><b>procedure</b></p><p><b>sequence</b>: 2</p><p><b>procedure</b>: Angioplasty of blood vessel <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="https://browser.ihtsdotools.org/">SNOMED CT</a>#418285008)</span></p></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><td><b>PreAuthRef</b></td></tr><tr><td style="display: none">*</td><td>1</td><td>true</td><td><a href="Coverage-example-02.html">Coverage/example-02</a></td><td>123456</td></tr></table><blockquote><p><b>item</b></p><p><b>sequence</b>: 1</p><p><b>careTeamSequence</b>: 1</p><p><b>productOrService</b>: Angiography <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="https://browser.ihtsdotools.org/">SNOMED CT</a>#77343006)</span></p><p><b>serviced</b>: 2023-12-09</p><h3>UnitPrices</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>10000.00</td><td>INR</td></tr></table><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>10000.00</td><td>INR</td></tr></table></blockquote><blockquote><p><b>item</b></p><p><b>sequence</b>: 2</p><p><b>careTeamSequence</b>: 1</p><p><b>productOrService</b>: Angioplasty of blood vessel <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="https://browser.ihtsdotools.org/">SNOMED CT</a>#418285008)</span></p><h3>UnitPrices</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>40000</td><td>INR</td></tr></table><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>40000</td><td>INR</td></tr></table></blockquote><blockquote><p><b>item</b></p><p><b>sequence</b>: 3</p><p><b>careTeamSequence</b>: 1</p><p><b>productOrService</b>: Intensive care unit <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="https://browser.ihtsdotools.org/">SNOMED CT</a>#309904001)</span></p><p><b>serviced</b>: 2023-12-11</p><p><b>quantity</b>: 10 day</p><h3>UnitPrices</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>2000</td><td>INR</td></tr></table><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>20000</td><td>INR</td></tr></table></blockquote><blockquote><p><b>item</b></p><p><b>sequence</b>: 4</p><p><b>careTeamSequence</b>: 1</p><p><b>productOrService</b>: Aspirin 75 mg oral tablet <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="https://browser.ihtsdotools.org/">SNOMED CT</a>#319775004)</span></p><h3>UnitPrices</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>100</td><td>INR</td></tr></table><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>100</td><td>INR</td></tr></table></blockquote><h3>Totals</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>70100</td><td>INR</td></tr></table></div>
  </text>
  <identifier>
    <system value="https://irdai.gov.in"/>
    <value value="7612345"/>
  </identifier>
  <status value="active"/>
  <type>
    <coding>
      <system value="http://snomed.info/sct"/>
      <code value="737481003"/>
      <display value="Inpatient care management (procedure)"/>
    </coding>
  </type>
  <subType>
    <coding>
      <system value="http://terminology.hl7.org/CodeSystem/ex-claimsubtype"/>
      <code value="emergency"/>
    </coding>
  </subType>
  <use value="predetermination"/>
  <patient>
    <reference value="Patient/example-01"/>
  </patient>
  <billablePeriod>
    <start value="2023-12-09T11:01:00+05:00"/>
    <end value="2023-12-30T11:01:00+05:00"/>
  </billablePeriod>
  <created value="2023-12-11T11:01:00+05:00"/>
  <insurer>
    <reference value="Organization/example-02"/>
  </insurer>
  <provider>
    <reference value="Organization/example-03"/>
  </provider>
  <priority>
    <coding>
      <system value="http://terminology.hl7.org/CodeSystem/processpriority"/>
      <code value="normal"/>
    </coding>
  </priority>
  <prescription>
    <reference value="MedicationRequest/example-03"/>
  </prescription>
  <careTeam>
    <sequence value="1"/>
    <provider>
      <reference value="Practitioner/example-01"/>
    </provider>
    <role>
      <coding>
        <system value="http://snomed.info/sct"/>
        <code value="223366009"/>
        <display value="Healthcare professional (occupation)"/>
      </coding>
    </role>
    <qualification>
      <coding>
        <system value="http://snomed.info/sct"/>
        <code value="394658006"/>
        <display value="Clinical specialty (qualifier value)"/>
      </coding>
    </qualification>
  </careTeam>
  <supportingInfo>
    <sequence value="1"/>
    <category>
      <coding>
        <system
                value="https://nrces.in/ndhm/fhir/r4/CodeSystem/ndhm-supportinginfo-category"/>
        <code value="INV"/>
        <display value="Document Type - Investigation"/>
      </coding>
    </category>
    <code>
      <coding>
        <system value="http://snomed.info/sct"/>
        <code value="77343006"/>
        <display value="Angiography"/>
      </coding>
    </code>
    <valueReference>
      <reference value="DocumentReference/example-03"/>
    </valueReference>
  </supportingInfo>
  <diagnosis>
    <sequence value="1"/>
    <diagnosisCodeableConcept>
      <coding>
        <system value="http://hl7.org/fhir/sid/icd-10"/>
        <code value="I46.9"/>
        <display value="Cardiac arrest, unspecified"/>
      </coding>
    </diagnosisCodeableConcept>
    <type>
      <coding>
        <system value="http://snomed.info/sct"/>
        <code value="89100005"/>
        <display
                 value="Final diagnosis (discharge) (contextual qualifier) (qualifier value)"/>
      </coding>
    </type>
  </diagnosis>
  <procedure>
    <sequence value="1"/>
    <procedureCodeableConcept>
      <coding>
        <system value="http://snomed.info/sct"/>
        <code value="77343006"/>
        <display value="Angiography"/>
      </coding>
    </procedureCodeableConcept>
  </procedure>
  <procedure>
    <sequence value="2"/>
    <procedureCodeableConcept>
      <coding>
        <system value="http://snomed.info/sct"/>
        <code value="418285008"/>
        <display value="Angioplasty of blood vessel"/>
      </coding>
    </procedureCodeableConcept>
  </procedure>
  <insurance>
    <sequence value="1"/>
    <focal value="true"/>
    <coverage>
      <reference value="Coverage/example-02"/>
    </coverage>
    <preAuthRef value="123456"/>
  </insurance>
  <item>
    <sequence value="1"/>
    <careTeamSequence value="1"/>
    <productOrService>
      <coding>
        <system value="http://snomed.info/sct"/>
        <code value="77343006"/>
        <display value="Angiography"/>
      </coding>
    </productOrService>
    <servicedDate value="2023-12-09"/>
    <unitPrice>
      <value value="10000.00"/>
      <currency value="INR"/>
    </unitPrice>
    <net>
      <value value="10000.00"/>
      <currency value="INR"/>
    </net>
  </item>
  <item>
    <sequence value="2"/>
    <careTeamSequence value="1"/>
    <productOrService>
      <coding>
        <system value="http://snomed.info/sct"/>
        <code value="418285008"/>
        <display value="Angioplasty of blood vessel"/>
      </coding>
    </productOrService>
    <unitPrice>
      <value value="40000"/>
      <currency value="INR"/>
    </unitPrice>
    <net>
      <value value="40000"/>
      <currency value="INR"/>
    </net>
  </item>
  <item>
    <sequence value="3"/>
    <careTeamSequence value="1"/>
    <productOrService>
      <coding>
        <system value="http://snomed.info/sct"/>
        <code value="309904001"/>
        <display value="Intensive care unit"/>
      </coding>
    </productOrService>
    <servicedDate value="2023-12-11"/>
    <quantity>
      <value value="10"/>
      <unit value="day"/>
    </quantity>
    <unitPrice>
      <value value="2000"/>
      <currency value="INR"/>
    </unitPrice>
    <net>
      <value value="20000"/>
      <currency value="INR"/>
    </net>
  </item>
  <item>
    <sequence value="4"/>
    <careTeamSequence value="1"/>
    <productOrService>
      <coding>
        <system value="http://snomed.info/sct"/>
        <code value="319775004"/>
        <display value="Aspirin 75 mg oral tablet"/>
      </coding>
    </productOrService>
    <unitPrice>
      <value value="100"/>
      <currency value="INR"/>
    </unitPrice>
    <net>
      <value value="100"/>
      <currency value="INR"/>
    </net>
  </item>
  <total>
    <value value="70100"/>
    <currency value="INR"/>
  </total>
</Claim>