ClaimResponseBundle-predetermination-example-01 - FHIR Implementation Guide for ABDM v6.0.0

This page is part of the FHIR Implementation Guide for ABDM (v6.0.0: Release) based on FHIR (HL7® FHIR® Standard) R4. This is the current published version in its permanent home (it will always be available at this URL). For a full list of available versions, see the Directory of published versions

Example Bundle: ClaimResponseBundle-predetermination-example-01

Bundle ClaimResponseBundle-predetermination-example-01 of type collection

Entry 1 - fullUrl = urn:uuid:da33ae8f-7d0c-4729-b909-0fe991bd4c08

Resource ClaimResponse:

Generated Narrative: ClaimResponse
Resource ClaimResponse "da33ae8f-7d0c-4729-b909-0fe991bd4c08"
Profile: ClaimResponse
status: ACTIVE
type: Inpatient care management (procedure) (SNOMED CT#737481003)
subType: Emergency Claim (Example Claim SubType Codes#emergency)
use: PREDETERMINATION
patient: See above (urn:uuid:7955f675-880f-48c4-94eb-b573ca1d1fc9: Patient)
created: 2023-12-12 15:32:26+0530
insurer: See above (urn:uuid:f42fe22c-ed56-458f-b1db-8800e005fb59: Organization)
requestor: See above (urn:uuid:0682cb2a-032b-4e08-80b1-80c866ece6cc: Organization)
request: See above (urn:uuid:253934fe-510d-49eb-98a5-6040665e9d47)
outcome: COMPLETE
preAuthRef: 123456
payeeType: Provider (Payee Type Codes#provider)
item
itemSequence: 1
adjudication
category: Eligible Amount (Adjudication Value Codes#eligible)
reason: Covered (SNOMED CT#255334000)
Amounts
- Value Currency
* 10000.00 INR
item
itemSequence: 2
adjudication
category: Eligible Amount (Adjudication Value Codes#eligible)
reason: Covered (SNOMED CT#255334000)
Amounts
- Value Currency
* 40000 INR
item
itemSequence: 3
adjudication
category: Eligible Amount (Adjudication Value Codes#eligible)
reason: Covered (SNOMED CT#255334000)
Amounts
- Value Currency
* 20000 INR
item
itemSequence: 4
adjudication
category: Eligible Amount (Adjudication Value Codes#eligible)
reason: Covered (SNOMED CT#255334000)
Amounts
- Value Currency
* 100 INR
total
category: Submitted Amount (Adjudication Value Codes#submitted)
Amounts
- Value Currency
* 70100 INR
Insurances
- Sequence Focal Coverage
* 1 true See above (urn:uuid:7120c410-1c60-4cfb-87ee-3cab3cbcc84b: Coverage)

Entry 2 - fullUrl = urn:uuid:253934fe-510d-49eb-98a5-6040665e9d47

Resource Claim:

Generated Narrative: Claim
Resource Claim "253934fe-510d-49eb-98a5-6040665e9d47"
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: PREDETERMINATION
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
* 1 See above (urn:uuid:ed3a499d-6de6-416e-884d-87f5c655b781: Practitioner) 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 (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#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 3 - fullUrl = urn:uuid:7955f675-880f-48c4-94eb-b573ca1d1fc9

Resource Patient:

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

Entry 4 - fullUrl = urn:uuid:f42fe22c-ed56-458f-b1db-8800e005fb59

Resource Organization:

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

Entry 5 - fullUrl = urn:uuid:0682cb2a-032b-4e08-80b1-80c866ece6cc

Resource Organization:

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.
Contacts
- Telecom
* +91 243 2634 1278, contact@xyz.org

Entry 6 - fullUrl = urn:uuid:18594b05-c0b4-476a-be6e-87cdd0f7cce6

Resource MedicationRequest:

Generated Narrative: MedicationRequest
Resource MedicationRequest "18594b05-c0b4-476a-be6e-87cdd0f7cce6"
Profile: MedicationRequest
status: ACTIVE
intent: ORDER
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)
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 7 - fullUrl = urn:uuid:ed3a499d-6de6-416e-884d-87f5c655b781

Resource Practitioner:

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

Entry 8 - fullUrl = urn:uuid:7120c410-1c60-4cfb-87ee-3cab3cbcc84b

Resource Coverage:

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

Entry 9 - fullUrl = urn:uuid:2093a577-8080-48bd-b9ee-17b1090b30d3

Resource Condition:

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

Entry 10 - fullUrl = urn:uuid:08707317-840a-4dfb-a061-c33c86b52fba

Resource DocumentReference:

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