This page is part of the FHIR Implementation Guide for ABDM (v6.5.0: Release) based on FHIR (HL7® FHIR® Standard) R4. This is the current published version. For a full list of available versions, see the Directory of published versions

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

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<Claim xmlns="http://hl7.org/fhir">
  <id value="Claim-preauthorization-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 class="res-header-id"><b>Generated Narrative: Claim Claim-preauthorization-example-01</b></p><a name="Claim-preauthorization-example-01"> </a><a name="hcClaim-preauthorization-example-01"> </a><a name="Claim-preauthorization-example-01-hi-IN"> </a><p><b>identifier</b>: 7612345</p><p><b>status</b>: Active</p><p><b>type</b>: <span title="Codes:{http://snomed.info/sct 737481003}">Inpatient care management (procedure)</span></p><p><b>subType</b>: <span title="Codes:{http://terminology.hl7.org/CodeSystem/ex-claimsubtype emergency}">Emergency Claim</span></p><p><b>use</b>: Preauthorization</p><p><b>patient</b>: <a href="Patient-example-01.html">ABC Male, DoB: 1981-01-12 ( Medical record number: 22-7225-4829-5255)</a></p><p><b>billablePeriod</b>: 2025-03-07 11:01:00+0500 --&gt; 2025-04-07 11:01:00+0500</p><p><b>created</b>: 2025-03-08 11:01:00+0500</p><p><b>insurer</b>: <a href="Organization-example-02.html">Organization XYZ Insurance Co. Ltd.</a></p><p><b>provider</b>: <a href="Organization-example-03.html">Organization XYZ Hospital Co. Ltd.</a></p><p><b>priority</b>: <span title="Codes:{http://terminology.hl7.org/CodeSystem/processpriority normal}">Normal</span></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 Dr. DEF</a></td><td><span title="Codes:{http://snomed.info/sct 223366009}">Healthcare professional (occupation)</span></td><td><span title="Codes:{http://snomed.info/sct 394658006}">Clinical specialty (qualifier value)</span></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><span title="Codes:{http://hl7.org/fhir/sid/icd-10 I46.9}">Cardiac arrest, unspecified</span></td><td><span title="Codes:{http://snomed.info/sct 89100005}">Final diagnosis (discharge) (contextual qualifier) (qualifier value)</span></td></tr></table><blockquote><p><b>procedure</b></p><p><b>sequence</b>: 1</p><p><b>procedure</b>: <span title="Codes:{http://snomed.info/sct 77343006}">Angiography</span></p></blockquote><blockquote><p><b>procedure</b></p><p><b>sequence</b>: 2</p><p><b>procedure</b>: <span title="Codes:{http://snomed.info/sct 418285008}">Angioplasty of blood vessel</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></tr><tr><td style="display: none">*</td><td>1</td><td>true</td><td><a href="Coverage-example-01.html">Coverage: identifier = https://xyzinsurance.in/policynumber/#235037120; status = active; type = PAY; subscriberId = ABC123456BI007; relationship = Self; period = (?) --&gt; 2026-03-17</a></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>: <span title="Codes:{http://snomed.info/sct 77343006}">Angiography</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>10000</td><td>Indian rupee</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</td><td>Indian rupee</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>: <span title="Codes:{http://snomed.info/sct 418285008}">Angioplasty of blood vessel</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>Indian rupee</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>Indian rupee</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>: <span title="Codes:{http://snomed.info/sct 309904001}">Intensive care unit</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>2000</td><td>Indian rupee</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>Indian rupee</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>70000</td><td>Indian rupee</td></tr></table></div>
  </text>
  <identifier>
    <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="preauthorization"/>
  <patient>🔗 
    <reference value="Patient/example-01"/>
  </patient>
  <billablePeriod>
    <start value="2025-03-07T11:01:00+05:00"/>
    <end value="2025-04-07T11:01:00+05:00"/>
  </billablePeriod>
  <created value="2025-03-08T11:01:00+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>
  <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>
  <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-01"/>
    </coverage>
  </insurance>
  <item>
    <sequence value="1"/>
    <careTeamSequence value="1"/>
    <productOrService>
      <coding>
        <system value="http://snomed.info/sct"/>
        <code value="77343006"/>
        <display value="Angiography"/>
      </coding>
    </productOrService>
    <unitPrice>
      <value value="10000"/>
      <currency value="INR"/>
    </unitPrice>
    <net>
      <value value="10000"/>
      <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>
    <unitPrice>
      <value value="2000"/>
      <currency value="INR"/>
    </unitPrice>
    <net>
      <value value="20000"/>
      <currency value="INR"/>
    </net>
  </item>
  <total>
    <value value="70000"/>
    <currency value="INR"/>
  </total>
</Claim>