This page is part of the T17 IG (v1.0.0: draft-1 Draft) 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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: t17-request - JSON Representation

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{
  "resourceType" : "CoverageEligibilityRequest",
  "id" : "t17-request",
  "meta" : {
    "profile" : [
      🔗 "http://ig.fhir-il-community.org/T17/StructureDefinition/t17-request"
    ]
  },
  "text" : {
    "status" : "generated",
    "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\">בקשה חדשה להתחייבות</div>"
  },
  "identifier" : [
    {
      "system" : "http://fhir.tlvmc.gov.il/identifier/preauth-req-no",
      "value" : "3772"
    }
  ],
  "status" : "active",
  "purpose" : [
    "validation"
  ],
  "patient" : {
    "reference" : "urn:uuid:8be7c2eb-07a2-4dfb-b27d-821863201199",
    "identifier" : {
      "system" : "http://fhir.leumit.co.il/identifier/magnetic-card",
      "value" : "1-123456-123456-789"
    }
  },
  "servicedDate" : "2023-07-02",
  "created" : "2023-07-04T04:52:03.001Z",
  "provider" : {
    "type" : "Organization",
    "identifier" : {
      "system" : "http://fhir.health.gov.il/identifier/legal-entity",
      "value" : "500106919"
    },
    "display" : "בי\"ח איכילוב"
  },
  "insurer" : {
    "identifier" : {
      "system" : "http://fhir.health.gov.il/identifier/legal-entity",
      "value" : "5899584495"
    },
    "display" : "מאוחדת"
  },
  "facility" : {
    "reference" : "urn:uuid:6e77f7eb-1693-4d19-b64b-b6ae92ec4aba",
    "type" : "Location"
  },
  "supportingInfo" : [
    {
      "sequence" : 1,
      "information" : {
        "reference" : "urn:uuid:792cc202-b6dd-4b45-bbf9-31358841836a",
        "type" : "Appointment"
      }
    },
    {
      "sequence" : 2,
      "information" : {
        "reference" : "urn:uuid:df9c48ad-f1a2-41a0-9755-7a5726cf6050",
        "type" : "DocumentReference",
        "display" : "מסמך סיכום ביקור עם המלצה לביקור חוזר"
      }
    }
  ],
  "item" : [
    {
      "productOrService" : {
        "coding" : [
          {
            "system" : "http://fhir.health.gov.il/cs/medical-service-moh",
            "code" : "L9258",
            "display" : "בדיקת רופא ילדים במרפאה"
          }
        ]
      },
      "quantity" : {
        "value" : 2
      },
      "unitPrice" : {
        "value" : 210,
        "currency" : "ILS"
      }
    },
    {
      "productOrService" : {
        "coding" : [
          {
            "system" : "http://fhir.health.gov.il/cs/medical-service-moh",
            "code" : "L9261",
            "display" : "תיאור קוד שירות L9261"
          }
        ]
      },
      "quantity" : {
        "value" : 1
      },
      "unitPrice" : {
        "value" : 242,
        "currency" : "ILS"
      }
    },
    {
      "productOrService" : {
        "coding" : [
          {
            "system" : "http://fhir.health.gov.il/cs/medical-service-moh",
            "code" : "L9266",
            "display" : "תיאור קוד שירות L9266"
          }
        ]
      },
      "quantity" : {
        "value" : 2
      },
      "unitPrice" : {
        "value" : 136,
        "currency" : "ILS"
      }
    },
    {
      "productOrService" : {
        "coding" : [
          {
            "system" : "http://fhir.health.gov.il/cs/medical-service-moh",
            "code" : "99242",
            "display" : "תיאור קוד שירות 99242"
          }
        ]
      },
      "quantity" : {
        "value" : 2
      },
      "unitPrice" : {
        "value" : 80,
        "currency" : "ILS"
      }
    }
  ]
}