ClaimBundle-preauthorization-example-01
type: Bundle
node role: treeRoot
id:
  v: ClaimBundle-preauthorization-example-01
meta:
  version id:
    v: 1
  last updated:
    v: 2023-12-11T15:32:26.605+05:30
  profile:
    v: https://nrces.in/ndhm/fhir/r4/StructureDefinition/ClaimBundle
    link: https://nrces.in/ndhm/fhir/r4/StructureDefinition/ClaimBundle
  security:
    system:
      v: http://terminology.hl7.org/CodeSystem/v3-Confidentiality
    code:
      v: V
    display:
      v: very restricted
identifier:
  system:
    v: http://hip.in
type:
  v: collection
timestamp:
  v: 2023-12-11T15:32:26.605+05:30

urn:…
type: Claim
meta:
  profile:
    v: https://nrces.in/ndhm/fhir/r4/StructureDefinition/Claim
    link: https://nrces.in/ndhm/fhir/r4/StructureDefinition/Claim
text:
  status:
    v: generated
  div: Generated Narrative: Claim Resource Claim "5790d1d0-7167-4502-a231-15fead40d24a" Profile: Claim identifier: https://irdai.gov.in/7612345 status: active type: Inpatient care management (procedure) (SNOMED CT#737481003) subType: Emergency Claim (Example Claim SubType Codes#emergency) use: preauthorization patient: See above (urn:uuid:7955f675-880f-48c4-94eb-b573ca1d1fc9: Patient) 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 (urn:uuid:f42fe22c-ed56-458f-b1db-8800e005fb59: Organization) provider: See above (urn:uuid:0682cb2a-032b-4e08-80b1-80c866ece6cc: Organization) priority: Normal (Process Priority Codes#normal) prescription: See above (urn:uuid:18594b05-c0b4-476a-be6e-87cdd0f7cce6: MedicationRequest) CareTeams - Sequence Provider Role Qualification * 1 See above (urn:uuid:ed3a499d-6de6-416e-884d-87f5c655b781: Practitioner) Healthcare professional (occupation) (SNOMED CT#223366009) Clinical specialty (qualifier value) (SNOMED CT#394658006) SupportingInfos - Sequence Category Code Value[x] * 1 Document Type - Investigation (SupportingInfo Category#INV) Angiography (SNOMED CT#77343006) See above (urn:uuid:08707317-840a-4dfb-a061-c33c86b52fba: DocumentReference) 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 (urn:uuid:7120c410-1c60-4cfb-87ee-3cab3cbcc84b: Coverage) 123456 item sequence: 1 careTeamSequence: 1 productOrService: Angiography (SNOMED CT#77343006) serviced: 2023-12-09 UnitPrices - Value Currency * 10000.0 INR Nets - Value Currency * 10000.0 INR item sequence: 2 careTeamSequence: 1 productOrService: Angioplasty of blood vessel (SNOMED CT#4182850…
identifier:
  system:
    v: https://irdai.gov.in
  value:
    v: 7612345
status:
  v: active
type:
  coding: http://snomed.info/id/737481003
    system:
      v: http://snomed.info/sct
    code:
      v: 737481003
    display:
      v: Inpatient care management (procedure)
sub type:
  coding:
    system:
      v: http://terminology.hl7.org/CodeSystem/ex-claimsubtype
    code:
      v: emergency
use:
  v: preauthorization
patient:
  display:
    v: Patient
billable period:
  start:
    v: 2023-12-09T11:01:00+05:00
  end:
    v: 2023-12-30T11:01:00+05:00
created:
  v: 2023-12-11T11:01:00+05:00
insurer:
  display:
    v: Organization
provider:
  display:
    v: Organization
priority:
  coding:
    system:
      v: http://terminology.hl7.org/CodeSystem/processpriority
    code:
      v: normal
prescription:
  display:
    v: MedicationRequest
care team:
  sequence:
    v: 1
  provider:
    display:
      v: Practitioner
  role:
    coding: http://snomed.info/id/223366009
      system:
        v: http://snomed.info/sct
      code:
        v: 223366009
      display:
        v: Healthcare professional (occupation)
  qualification:
    coding: http://snomed.info/id/394658006
      system:
        v: http://snomed.info/sct
      code:
        v: 394658006
      display:
        v: Clinical specialty (qualifier value)
supporting info:
  sequence:
    v: 1
  category:
    coding:
      system:
        v: https://nrces.in/ndhm/fhir/r4/CodeSystem/ndhm-supportinginfo-category
      code:
        v: INV
      display:
        v: Document Type - Investigation
  code:
    coding: http://snomed.info/id/77343006
      system:
        v: http://snomed.info/sct
      code:
        v: 77343006
      display:
        v: Angiography
  value: Reference
    display:
      v: DocumentReference
diagnosis:
  sequence:
    v: 1
  diagnosis: CodeableConcept
    coding:
      system:
        v: http://hl7.org/fhir/sid/icd-10
      code:
        v: I46.9
      display:
        v: Cardiac arrest, unspecified
  type:
    coding: http://snomed.info/id/89100005
      system:
        v: http://snomed.info/sct
      code:
        v: 89100005
      display:
        v: Final diagnosis (discharge) (contextual qualifier) (qualifier value)
procedure:
  sequence:
    v: 1
  procedure: CodeableConcept
    coding: http://snomed.info/id/77343006
      system:
        v: http://snomed.info/sct
      code:
        v: 77343006
      display:
        v: Angiography
procedure:
  sequence:
    v: 2
  procedure: CodeableConcept
    coding: http://snomed.info/id/418285008
      system:
        v: http://snomed.info/sct
      code:
        v: 418285008
      display:
        v: Angioplasty of blood vessel
insurance:
  sequence:
    v: 1
  focal:
    v: true
  coverage:
    display:
      v: Coverage
  pre auth ref:
    v: 123456
item:
  sequence:
    v: 1
  care team sequence:
    v: 1
  product or service:
    coding: http://snomed.info/id/77343006
      system:
        v: http://snomed.info/sct
      code:
        v: 77343006
      display:
        v: Angiography
  serviced:
    v: 2023-12-09
  unit price:
    value:
      v: 10000.0
    currency:
      v: INR
  net:
    value:
      v: 10000.0
    currency:
      v: INR
item:
  sequence:
    v: 2
  care team sequence:
    v: 1
  product or service:
    coding: http://snomed.info/id/418285008
      system:
        v: http://snomed.info/sct
      code:
        v: 418285008
      display:
        v: Angioplasty of blood vessel
  unit price:
    value:
      v: 40000
    currency:
      v: INR
  net:
    value:
      v: 40000
    currency:
      v: INR

urn:…
type: Patient
meta:
  version id:
    v: 1
  last updated:
    v: 2023-09-07T14:58:58.181+05:30
  profile:
    v: https://nrces.in/ndhm/fhir/r4/StructureDefinition/Patient
    link: https://nrces.in/ndhm/fhir/r4/StructureDefinition/Patient
text:
  status:
    v: generated
  div: Generated Narrative: Patient Resource Patient "7955f675-880f-48c4-94eb-b573ca1d1fc9" Version "1" Updated "2023-09-07 14:58:58+0530" Profile: Patient identifier: Adhaar number/7225-4829-5255 name: Adarsh Agrawal telecom: +919818512600 gender: male birthDate: 1981-01-12
identifier:
  type:
    coding:
      system:
        v: https://nrces.in/ndhm/fhir/r4/CodeSystem/ndhm-identifier-type-code
      code:
        v: ADN
      display:
        v: Adhaar number
  system:
    v: https://uidai.gov.in/
  value:
    v: 7225-4829-5255
name:
  text:
    v: Adarsh Agrawal
telecom:
  system:
    v: phone
  value:
    v: +919818512600
  use:
    v: home
gender:
  v: male
birth date:
  v: 1981-01-12

urn:…
type: Organization
meta:
  profile:
    v: https://nrces.in/ndhm/fhir/r4/StructureDefinition/Organization
    link: https://nrces.in/ndhm/fhir/r4/StructureDefinition/Organization
text:
  status:
    v: generated
  div: Generated Narrative: Organization Resource Organization "f42fe22c-ed56-458f-b1db-8800e005fb59" Profile: Organization identifier: Provider number/4567878 type: Insurance Company (Organization type#ins) name: XYZ Insurance Co. Ltd. telecom: +91 243 2634 1234, contact@xyz.org
identifier:
  type:
    coding:
      system:
        v: http://terminology.hl7.org/CodeSystem/v2-0203
      code:
        v: PRN
      display:
        v: Provider number
  system:
    v: https://facility.ndhm.gov.in
  value:
    v: 4567878
type:
  coding:
    system:
      v: http://terminology.hl7.org/CodeSystem/organization-type
    code:
      v: ins
    display:
      v: Insurance Company
name:
  v: XYZ Insurance Co. Ltd.
telecom:
  system:
    v: phone
  value:
    v: +91 243 2634 1234
  use:
    v: work
telecom:
  system:
    v: email
  use:
    v: work

urn:…
type: Organization
meta:
  profile:
    v: https://nrces.in/ndhm/fhir/r4/StructureDefinition/Organization
    link: https://nrces.in/ndhm/fhir/r4/StructureDefinition/Organization
text:
  status:
    v: generated
  div: Generated Narrative: Organization Resource Organization "0682cb2a-032b-4e08-80b1-80c866ece6cc" Profile: Organization identifier: Provider number/45675454 type: Healthcare Provider (Organization type#prov) name: XYZ Hospital Co. Ltd. telecom: +91 243 2634 1278, contact@xyz.org
identifier:
  type:
    coding:
      system:
        v: http://terminology.hl7.org/CodeSystem/v2-0203
      code:
        v: PRN
      display:
        v: Provider number
  system:
    v: https://facility.ndhm.gov.in
  value:
    v: 45675454
type:
  coding:
    system:
      v: http://terminology.hl7.org/CodeSystem/organization-type
    code:
      v: prov
    display:
      v: Healthcare Provider
name:
  v: XYZ Hospital Co. Ltd.
telecom:
  system:
    v: phone
  value:
    v: +91 243 2634 1278
  use:
    v: work
telecom:
  system:
    v: email
  use:
    v: work

urn:…
type: MedicationRequest
meta:
  profile:
    v: https://nrces.in/ndhm/fhir/r4/StructureDefinition/MedicationRequest
    link: https://nrces.in/ndhm/fhir/r4/StructureDefinition/MedicationRequest
text:
  status:
    v: generated
  div: Generated Narrative: MedicationRequest Resource MedicationRequest "18594b05-c0b4-476a-be6e-87cdd0f7cce6" Profile: MedicationRequest status: active intent: order medication: Aspirin 75 mg oral tablet (SNOMED CT#319775004) subject: See above (urn:uuid:7955f675-880f-48c4-94eb-b573ca1d1fc9: Patient) authoredOn: 2023-12-11 requester: See above (urn:uuid:ed3a499d-6de6-416e-884d-87f5c655b781: Practitioner) reasonCode: Cardiac arrest (SNOMED CT#410429000) reasonReference: See above (urn:uuid:2093a577-8080-48bd-b9ee-17b1090b30d3: Condition) 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)
status:
  v: active
intent:
  v: order
medication: CodeableConcept
  coding: http://snomed.info/id/319775004
    system:
      v: http://snomed.info/sct
    code:
      v: 319775004
    display:
      v: Aspirin 75 mg oral tablet
subject:
  display:
    v: Patient
authored on:
  v: 2023-12-11
requester:
  display:
    v: Practitioner
reason code:
  coding: http://snomed.info/id/410429000
    system:
      v: http://snomed.info/sct
    code:
      v: 410429000
    display:
      v: Cardiac arrest
reason reference:
  display:
    v: Condition
dosage instruction:
  text:
    v: One tablet at once
  additional instruction:
    coding: http://snomed.info/id/311504000
      system:
        v: http://snomed.info/sct
      code:
        v: 311504000
      display:
        v: With or after food
  timing:
    repeat:
      frequency:
        v: 1
      period:
        v: 1
      period unit:
        v: d
  route:
    coding: http://snomed.info/id/26643006
      system:
        v: http://snomed.info/sct
      code:
        v: 26643006
      display:
        v: Oral Route
  method:
    coding: http://snomed.info/id/421521009
      system:
        v: http://snomed.info/sct
      code:
        v: 421521009
      display:
        v: Swallow

urn:…
type: Practitioner
meta:
  version id:
    v: 1
  last updated:
    v: 2023-09-07T14:58:58.181+05:30
  profile:
    v: https://nrces.in/ndhm/fhir/r4/StructureDefinition/Practitioner
    link: https://nrces.in/ndhm/fhir/r4/StructureDefinition/Practitioner
text:
  status:
    v: generated
  div: Generated Narrative: Practitioner Resource Practitioner "ed3a499d-6de6-416e-884d-87f5c655b781" Version "1" Updated "2023-09-07 14:58:58+0530" Profile: Practitioner identifier: Medical License number/21-1521-3828-3227 name: Dr. Aayush Agrawal
identifier:
  type:
    coding:
      system:
        v: http://terminology.hl7.org/CodeSystem/v2-0203
      code:
        v: MD
      display:
        v: Medical License number
  system:
    v: https://doctor.ndhm.gov.in
  value:
    v: 21-1521-3828-3227
name:
  text:
    v: Dr. Aayush Agrawal

urn:…
type: Coverage
meta:
  profile:
    v: https://nrces.in/ndhm/fhir/r4/StructureDefinition/Coverage
    link: https://nrces.in/ndhm/fhir/r4/StructureDefinition/Coverage
text:
  status:
    v: generated
  div: Generated Narrative: Coverage Resource Coverage "7120c410-1c60-4cfb-87ee-3cab3cbcc84b" Profile: Coverage identifier: https://xyzinsurance.in/policynumber//235037120 status: active type: PAY (Coverage SelfPay Codes#pay) subscriber: See above (urn:uuid:7955f675-880f-48c4-94eb-b573ca1d1fc9: Patient) subscriberId: ABC123456BI007 beneficiary: See above (urn:uuid:7955f675-880f-48c4-94eb-b573ca1d1fc9: Patient) relationship: Self (SubscriberPolicyholder Relationship Codes#self) period: ?? --> 2026-03-17 payor: See above (urn:uuid:f42fe22c-ed56-458f-b1db-8800e005fb59: Organization)
identifier:
  system:
    v: https://xyzinsurance.in/policynumber/
  value:
    v: 235037120
status:
  v: active
type:
  coding:
    system:
      v: http://terminology.hl7.org/CodeSystem/coverage-selfpay
    code:
      v: pay
    display:
      v: PAY
subscriber:
  display:
    v: Patient
subscriber id:
  v: ABC123456BI007
beneficiary:
  display:
    v: Patient
relationship:
  coding:
    system:
      v: http://terminology.hl7.org/CodeSystem/subscriber-relationship
    code:
      v: self
period:
  end:
    v: 2026-03-17
payor:
  display:
    v: Organization

urn:…
type: Condition
meta:
  profile:
    v: https://nrces.in/ndhm/fhir/r4/StructureDefinition/Condition
    link: https://nrces.in/ndhm/fhir/r4/StructureDefinition/Condition
text:
  status:
    v: generated
  div: Generated Narrative: Condition Resource Condition "2093a577-8080-48bd-b9ee-17b1090b30d3" Profile: Condition code: Cardiac arrest, unspecified (ICD-10#I46.9) subject: See above (urn:uuid:7955f675-880f-48c4-94eb-b573ca1d1fc9: Patient) onset: 2days recorder: See above (urn:uuid:ed3a499d-6de6-416e-884d-87f5c655b781: Practitioner)
code:
  coding:
    system:
      v: http://hl7.org/fhir/sid/icd-10
    code:
      v: I46.9
    display:
      v: Cardiac arrest, unspecified
subject:
  display:
    v: Patient
onset:
  v: 2days
recorder:
  display:
    v: Practitioner

urn:…
type: DocumentReference
meta:
  profile:
    v: https://nrces.in/ndhm/fhir/r4/StructureDefinition/DocumentReference
    link: https://nrces.in/ndhm/fhir/r4/StructureDefinition/DocumentReference
text:
  status:
    v: generated
  div: Generated Narrative: DocumentReference Resource DocumentReference "08707317-840a-4dfb-a061-c33c86b52fba" Profile: DocumentReference status: current docStatus: final subject: See above (urn:uuid:7955f675-880f-48c4-94eb-b573ca1d1fc9: Patient) content Attachments - ContentType Language Data Title Creation * application/pdf en-IN (base64 data - 80793 bytes) Angiography PDF 2019-05-29 14:58:58+0530
status:
  v: current
doc status:
  v: final
subject:
  display:
    v: Patient
content:
  attachment:
    content type:
      v: application/pdf
    language:
      v: en-IN
    title:
      v: Angiography PDF
    creation:
      v: 2019-05-29T14:58:58.181+05:30

sequence:
  v: 3
care team sequence:
  v: 1
product or service:
  coding: http://snomed.info/id/309904001
    system:
      v: http://snomed.info/sct
    code:
      v: 309904001
    display:
      v: Intensive care unit
serviced:
  v: 2023-12-11
quantity:
  value:
    v: 10
  unit:
    v: day
unit price:
  value:
    v: 2000
  currency:
    v: INR
net:
  value:
    v: 20000
  currency:
    v: INR

sequence:
  v: 4
care team sequence:
  v: 1
product or service:
  coding: http://snomed.info/id/319775004
    system:
      v: http://snomed.info/sct
    code:
      v: 319775004
    display:
      v: Aspirin 75 mg oral tablet
unit price:
  value:
    v: 100
  currency:
    v: INR
net:
  value:
    v: 100
  currency:
    v: INR

value:
  v: 70100
currency:
  v: INR