@prefix fhir: . @prefix owl: . @prefix rdf: . @prefix rdfs: . @prefix sct: . @prefix xsd: . # - resource ------------------------------------------------------------------- a fhir:ClaimResponse ; fhir:nodeRole fhir:treeRoot ; fhir:id [ fhir:v "ClaimResponse-predetermination-example-01"] ; # fhir:meta [ fhir:profile ( [ fhir:v "https://nrces.in/ndhm/fhir/r4/StructureDefinition/ClaimResponse"^^xsd:anyURI ; fhir:link ] ) ] ; # fhir:text [ fhir:status [ fhir:v "generated" ] ; fhir:div "

Generated Narrative: ClaimResponse ClaimResponse-predetermination-example-01

status: Active

type: Inpatient care management (procedure)

use: Predetermination

patient: ABC Male, DoB: 1981-01-12 ( Medical record number: 22-7225-4829-5255)

created: 2023-12-12 15:32:26+0530

insurer: Organization XYZ Insurance Co. Ltd.

requestor: Organization XYZ Hospital Co. Ltd.

request: Claim: identifier = 7612345; status = active; type = Inpatient care management (procedure); subType = Emergency Claim; use = predetermination; billablePeriod = 2025-03-07 11:01:00+0500 --> 2025-04-07 11:01:00+0500; created = 2025-03-07 11:01:00+0500; priority = Normal

outcome: Processing Complete

preAuthRef: 123456

payeeType: Provider

item

itemSequence: 1

adjudication

category: Submitted Amount

Amounts

-ValueCurrency
*10000Indian rupee

adjudication

category: Eligible %

reason: Product or Service requested is covered by the policy.

Amounts

-ValueCurrency
*10000Indian rupee

item

itemSequence: 2

adjudication

category: Submitted Amount

Amounts

-ValueCurrency
*40000Indian rupee

adjudication

category: Eligible %

reason: Product or Service requested is covered by the policy.

Amounts

-ValueCurrency
*40000Indian rupee

item

itemSequence: 3

adjudication

category: Submitted Amount

Amounts

-ValueCurrency
*20000Indian rupee

adjudication

category: Eligible %

reason: Product or Service requested is covered by the policy.

Amounts

-ValueCurrency
*20000Indian rupee

total

category: Submitted Amount

Amounts

-ValueCurrency
*70000Indian rupee

total

category: Eligible %

Amounts

-ValueCurrency
*70000Indian rupee

Insurances

-SequenceFocalCoverage
*1trueCoverage: identifier = https://xyzinsurance.in/policynumber/#235037120; status = active; type = PAY; subscriberId = ABC123456BI007; relationship = Self; period = (?) --> 2026-03-17
"^^rdf:XMLLiteral ] ; # fhir:status [ fhir:v "active"] ; # fhir:type [ fhir:coding ( [ a sct:737481003 ; fhir:system [ fhir:v "http://snomed.info/sct"^^xsd:anyURI ] ; fhir:code [ fhir:v "737481003" ] ; fhir:display [ fhir:v "Inpatient care management (procedure)" ] ] ) ] ; # fhir:use [ fhir:v "predetermination"] ; # fhir:patient [ fhir:link ; fhir:reference [ fhir:v "Patient/example-01" ] ] ; # fhir:created [ fhir:v "2023-12-12T15:32:26.605+05:30"^^xsd:dateTime] ; # fhir:insurer [ fhir:link ; fhir:reference [ fhir:v "Organization/example-02" ] ] ; # fhir:requestor [ fhir:link ; fhir:reference [ fhir:v "Organization/example-03" ] ] ; # fhir:request [ fhir:link ; fhir:reference [ fhir:v "Claim/Claim-predetermination-example-01" ] ] ; # fhir:outcome [ fhir:v "complete"] ; # fhir:preAuthRef [ fhir:v "123456"] ; # fhir:payeeType [ fhir:coding ( [ fhir:system [ fhir:v "http://terminology.hl7.org/CodeSystem/payeetype"^^xsd:anyURI ] ; fhir:code [ fhir:v "provider" ] ] ) ] ; # fhir:item ( [ fhir:itemSequence [ fhir:v "1"^^xsd:positiveInteger ] ; fhir:adjudication ( [ fhir:category [ fhir:coding ( [ fhir:system [ fhir:v "http://terminology.hl7.org/CodeSystem/adjudication"^^xsd:anyURI ] ; fhir:code [ fhir:v "submitted" ] ; fhir:display [ fhir:v "Submitted Amount" ] ] ) ] ; fhir:amount [ fhir:value [ fhir:v "10000"^^xsd:decimal ] ; fhir:currency [ fhir:v "INR" ] ] ] [ fhir:category [ fhir:coding ( [ fhir:system [ fhir:v "http://terminology.hl7.org/CodeSystem/adjudication"^^xsd:anyURI ] ; fhir:code [ fhir:v "eligpercent" ] ; fhir:display [ fhir:v "Eligible %" ] ] ) ] ; fhir:reason [ fhir:coding ( [ fhir:system [ fhir:v "https://nrces.in/ndhm/fhir/r4/CodeSystem/ndhm-adjudication-reason"^^xsd:anyURI ] ; fhir:code [ fhir:v "covered" ] ; fhir:display [ fhir:v "Product or Service requested is covered by the policy." ] ] ) ] ; fhir:amount [ fhir:value [ fhir:v "10000"^^xsd:decimal ] ; fhir:currency [ fhir:v "INR" ] ] ] ) ] [ fhir:itemSequence [ fhir:v "2"^^xsd:positiveInteger ] ; fhir:adjudication ( [ fhir:category [ fhir:coding ( [ fhir:system [ fhir:v "http://terminology.hl7.org/CodeSystem/adjudication"^^xsd:anyURI ] ; fhir:code [ fhir:v "submitted" ] ; fhir:display [ fhir:v "Submitted Amount" ] ] ) ] ; fhir:amount [ fhir:value [ fhir:v "40000"^^xsd:decimal ] ; fhir:currency [ fhir:v "INR" ] ] ] [ fhir:category [ fhir:coding ( [ fhir:system [ fhir:v "http://terminology.hl7.org/CodeSystem/adjudication"^^xsd:anyURI ] ; fhir:code [ fhir:v "eligpercent" ] ; fhir:display [ fhir:v "Eligible %" ] ] ) ] ; fhir:reason [ fhir:coding ( [ fhir:system [ fhir:v "https://nrces.in/ndhm/fhir/r4/CodeSystem/ndhm-adjudication-reason"^^xsd:anyURI ] ; fhir:code [ fhir:v "covered" ] ; fhir:display [ fhir:v "Product or Service requested is covered by the policy." ] ] ) ] ; fhir:amount [ fhir:value [ fhir:v "40000"^^xsd:decimal ] ; fhir:currency [ fhir:v "INR" ] ] ] ) ] [ fhir:itemSequence [ fhir:v "3"^^xsd:positiveInteger ] ; fhir:adjudication ( [ fhir:category [ fhir:coding ( [ fhir:system [ fhir:v "http://terminology.hl7.org/CodeSystem/adjudication"^^xsd:anyURI ] ; fhir:code [ fhir:v "submitted" ] ; fhir:display [ fhir:v "Submitted Amount" ] ] ) ] ; fhir:amount [ fhir:value [ fhir:v "20000"^^xsd:decimal ] ; fhir:currency [ fhir:v "INR" ] ] ] [ fhir:category [ fhir:coding ( [ fhir:system [ fhir:v "http://terminology.hl7.org/CodeSystem/adjudication"^^xsd:anyURI ] ; fhir:code [ fhir:v "eligpercent" ] ; fhir:display [ fhir:v "Eligible %" ] ] ) ] ; fhir:reason [ fhir:coding ( [ fhir:system [ fhir:v "https://nrces.in/ndhm/fhir/r4/CodeSystem/ndhm-adjudication-reason"^^xsd:anyURI ] ; fhir:code [ fhir:v "covered" ] ; fhir:display [ fhir:v "Product or Service requested is covered by the policy." ] ] ) ] ; fhir:amount [ fhir:value [ fhir:v "20000"^^xsd:decimal ] ; fhir:currency [ fhir:v "INR" ] ] ] ) ] ) ; # fhir:total ( [ fhir:category [ fhir:coding ( [ fhir:system [ fhir:v "http://terminology.hl7.org/CodeSystem/adjudication"^^xsd:anyURI ] ; fhir:code [ fhir:v "submitted" ] ; fhir:display [ fhir:v "Submitted Amount" ] ] ) ] ; fhir:amount [ fhir:value [ fhir:v "70000"^^xsd:decimal ] ; fhir:currency [ fhir:v "INR" ] ] ] [ fhir:category [ fhir:coding ( [ fhir:system [ fhir:v "http://terminology.hl7.org/CodeSystem/adjudication"^^xsd:anyURI ] ; fhir:code [ fhir:v "eligpercent" ] ; fhir:display [ fhir:v "Eligible %" ] ] ) ] ; fhir:amount [ fhir:value [ fhir:v "70000"^^xsd:decimal ] ; fhir:currency [ fhir:v "INR" ] ] ] ) ; # fhir:insurance ( [ fhir:sequence [ fhir:v "1"^^xsd:positiveInteger ] ; fhir:focal [ fhir:v "true"^^xsd:boolean ] ; fhir:coverage [ fhir:link ; fhir:reference [ fhir:v "Coverage/example-01" ] ] ] ) . # # -------------------------------------------------------------------------------------