醫療保險理賠實作指引
1.0.0 - CI Build
醫療保險理賠實作指引
1.0.0 - CI Build
醫療保險理賠實作指引 - Local Development build (v1.0.0) built by the FHIR (HL7® FHIR® Standard) Build Tools. See the Directory of published versions
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<div xmlns="http://www.w3.org/1999/xhtml"><h3><b>Composition</b></h3><p><b>文件識別碼</b>：A0002 (https://www.cgh.org.tw)</p><p><b>文件狀態</b>：Final <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki">(<a href="http://hl7.org/fhir/R4/valueset-composition-status.html">CompositionStatus</a>#final)</span></p><p><b>文件種類</b>：Charge ticket or encounter form <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki">( <a href="https://loinc.org/">LOINC</a>#64291-8)</span></p><p><b>文件創建日期</b>：2023-08-21T14:30:00+08:00</p><p><b>文件創建單位</b>：<a href="Organization-Organization-min.html">Organization/Organization-min</a> "國泰醫療財團法人國泰綜合醫院"</p><p><b>病人</b>：<a href="Patient-Patient-C2.html">Patient/Patient-C2</a> "康美女"</p><p><b>section.entry[iClaim]</b>：<a href="Claim-Claim-C2.html">Claim/Claim-C2</a></p><p><b>section.entry[condition]</b>：<a href="Condition-Condition-C2.html">Condition/Condition-C2</a></p><p><b>section.entry[encounter]</b>：<a href="Encounter-Encounter-C2.html">Encounter/Encounter-C2</a></p><p><b>section.entry[coverage]</b>：<a href="Coverage-Coverage-C2.html">Coverage/Coverage-C2</a></p><p><b>section.entry[payor]</b>：<a href="Organization-Organization-cathay.html">Organization/Organization-cathay</a></p><p><b>section.entry[practitioner]</b>：<a href="Practitioner-Practitioner-Wang.html">Practitioner/Practitioner-Wang</a></p><p><b>section.entry[practitioner]</b>：<a href="Practitioner-Practitioner-Ciou2.html">Practitioner/Practitioner-Ciou2</a></p></div>
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<div xmlns="http://www.w3.org/1999/xhtml"><p><b>理賠申請書編號</b>：A0002 (https://www.cgh.org.tw)</p><p><b>理賠申請書狀態</b>: Active <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki">(<a href="http://hl7.org/fhir/R4/codesystem-fm-status.html">Financial Resource Status Codes</a>#active)</span></p><p><b>理賠申請書類別</b>: Institutional <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki">(<a href="http://terminology.hl7.org/5.0.0/CodeSystem-claim-type.html">Claim Type Codes</a>#institutional)</span></p><p><b>理賠申請書用途</b>: Claim <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki">(<a href="http://hl7.org/fhir/R4/codesystem-claim-use.html">Use</a>#claim)</span></p><p><b>病人</b>： <a href="Patient-Patient-C2.html">Patient/Patient-C2</a> "康美女"</p><p><b>理賠申請書日期</b>: 2023-08-08</p><p><b>醫院</b>： <a href="Organization-Organization-min.html">Organization/Organization-min</a> "國泰醫療財團法人國泰綜合醫院"</p><p><b>處理優先順序</b>: Immediate <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki">(<a href="http://terminology.hl7.org/5.0.0/CodeSystem-processpriority.html">Process Priority Codes</a>#stat)</span></p><p><b>診斷證明書</b>：</p><table class="grid"><tr><td style="display: none">-</td><td><b>順序</b></td><td><b>Diagnosis[x]</b></td></tr><tr><td style="display: none">*</td><td>1</td><td><a href="Condition-Condition-C2.html">Condition/Condition-C2</a></td></tr></table><p><b>保險</b>：</p><table class="grid"><tr><td style="display: none">-</td><td><b>順序</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-Coverage-C2.html">Coverage/Coverage-C2</a></td></tr></table><blockquote><p><b>收據</b>：</p><p><b>費用序號</b>: 1</p><p><b>自付金額（base price）/減免（discount）</b>: 自付金額 <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki">(<a href="http://hl7.org/fhir/R4/codesystem-invoice-priceComponentType.html">InvoicePriceComponentType</a>#base)</span></p><p><b>費用項目</b>: 掛號費 <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki">(<a href="CodeSystem-cathay-chargeitemcode-values.html">費用項目-健保</a>#REGISTRATION)</span></p><p><b>就醫身分</b>: 自費 <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki">(<a href="http://terminology.hl7.org/5.0.0/CodeSystem-coverage-selfpay.html">Coverage SelfPay Codes</a>#pay)</span></p><p><b>收據日期</b>: 2023-08-08</p><p><b>自付金額</b>：150</p><p><b>費用序號</b>: 2</p><p><b>費用項目</b>: 掛號費 <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki">(<a href="CodeSystem-cathay-chargeitemcode-values.html">費用項目-健保</a>#REGISTRATION)</span></p><p><b>就醫身分</b>: 健保 <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki">(<a href="https://terminology.hl7.org/5.0.0/CodeSystem-v3-ActCode.html">ActCode</a>#PUBLICPOL)</span></p><p><b>收據日期</b>: 2023-08-08</p><p><b>健保點數</b>：580</p><p><b>總費用</b>：150</p></blockquote></div>
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<div xmlns="http://www.w3.org/1999/xhtml"><h3><b>病人基本資料</b></h3><blockquote><p><b>識別碼型別</b>：National Person Identifier <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki">（ <a href="http://terminology.hl7.org/CodeSystem/v2-0203">Identifier Type Codes</a>#NNxxx <b>[extension: <a href="https://twcore.mohw.gov.tw/ig/twcore/StructureDefinition/identifier-suffix">Identifier Suffix</a>]：</b>TWN）</span><br/><b>身分證字號（official）</b>G252862637 （http://www.moi.gov.tw）</p></blockquote><blockquote><p><b>識別碼型別</b>：Medical record number <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki">（ <a href="http://terminology.hl7.org/CodeSystem/v2-0203">Identifier Type Codes</a>#MR）</span><br/><b>病歷號（official）</b>：ADCM5678 （https://www.cgh.org.tw）</p></blockquote><p><b>姓名（official）</b>：康美女</p><p><b>性別</b>：Female <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki">( <a href="http://hl7.org/fhir/R4/codesystem-administrative-gender.html">AdministrativeGender</a>#female)</span></p><p><b>出生日期</b>：2002-01-08</p><p><b>職業[extension: <a href="StructureDefinition-cathay-occupation.html">Occupation</a>]</b>：內勤人員 <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki">( <a href="CodeSystem-lia-roc-occupation-values.html">Occupation</a>#00010010)</span></p><p><b>聯絡地址</b>：台北市北投區明德路365號<br/><b> 縣/市（district）</b>：台北市<br/><b> 鄉/鎮/市/區（city）</b>：北投區<br/><b> 路/街（line）</b>：明德路<br/><b> 號（number）</b>[extension: <a href="https://twcore.mohw.gov.tw/ig/twcore/StructureDefinition/tw-number">tw-number</a>]：365號<br/><b> 國家（country）</b>：臺灣<br/></p></div>
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<div xmlns="http://www.w3.org/1999/xhtml"><h3><b>醫事機構基本資料</b></h3><p><b>機構名稱</b>：國泰醫療財團法人國泰綜合醫院</p><p><b>識別碼型別</b>：Provider number<span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki">（ <a href="http://terminology.hl7.org/CodeSystem/v2-0203">IdentifierType</a>#PRN）</span><br/><b>機構代碼（official）</b>：1101020018 (https://twcore.mohw.gov.tw/ig/twcore/CodeSystem/organization-identifier-tw)</p><p><b>機構種類</b>：Healthcare Provider <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki">( <a href="http://hl7.org/fhir/R4/codesystem-organization-type.html">OrganizationType</a>#prov)</span></p></div>
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<div xmlns="http://www.w3.org/1999/xhtml"><p><b>status</b>: active <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki">（ <a href="https://hl7.org/fhir/R4/codesystem-fm-status.html">FinancialResourceStatusCodes</a>#active ）</span></p><p><b>beneficiary</b>： <a href="Patient-Patient-C2.html">Patient/Patient-C2</a> "康美女"</p><p><b>payor</b>： <a href="Organization-Organization-cathay.html">Organization/Organization-cathay</a> "國泰人壽保險股份有限公司"</p></div>
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<div xmlns="http://www.w3.org/1999/xhtml"><h3><b>公司行號基本資料</b></h3><p><b>機構名稱</b>：國泰人壽保險股份有限公司</p><p><b>識別碼型別</b>：Unified Business number<span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki">（ <a href="https://twcore.mohw.gov.tw/ig/twcore/CodeSystem/v2-0203">臺灣識別碼類型</a>#UBN）</span><br/><b>公司或企業統一編號（official）</b>：03374707 (https://gcis.nat.gov.tw)</p><p><b>機構種類</b>：Non-Healthcare Business or Corporation <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki">( <a href="http://hl7.org/fhir/R4/codesystem-organization-type.html">OrganizationType</a>#bus)</span></p></div>
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<div xmlns="http://www.w3.org/1999/xhtml"><h3><b>病情、問題或診斷資料</b></h3><p><b>病情、問題或診斷識別碼</b>：1080108643</p><p><b>臨床狀態</b>：Active <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki">( <a href="http://hl7.org/fhir/R4/codesystem-condition-clinical.html">ConditionClinicalStatusCodes</a>#active)</span></p><p><b>病情、問題或診斷類別</b>：Encounter Diagnosis <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki">( <a href="http://hl7.org/fhir/R4/valueset-condition-category.html">Condition Category Codes</a>#encounter-diagnosis)</span></p><p><b>病情、問題或診斷識別</b>：便秘 <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki">( <a href="https://twcore.mohw.gov.tw/ig/twcore/CodeSystem-icd-9-cm-2001-tw.html">NHIICD9CM</a>#564.0)</span></p><p><b>病人</b>：<a href="Patient-Patient-C2.html">Patient/Patient-C2</a> "康美女"</p><p><b>就醫（Encounter）紀錄</b>：<a href="Encounter-Encounter-C2.html">Encounter/Encounter-C2</a></p><p><b>記錄日期</b>：2023-08-08</p><p><b>主治醫師</b>：<a href="PractitionerRole-PractitionerRole-pri2.html">PractitionerRole/PractitionerRole-pri2</a> "王建胃"</p><p><b>負責醫師（院長）</b>：<a href="PractitionerRole-PractitionerRole-res2.html">PractitionerRole/PractitionerRole-res2</a> "邱榮二"</p><p><b>醫療摘要</b>：腹部的膨脹感、腹痛、腸脹氣，而且在排便之後才能得到緩解。</p></div>
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</asserter>
<note>
<text value="腹部的膨脹感、腹痛、腸脹氣，而且在排便之後才能得到緩解。"/>
</note>
</Condition>
</resource>
</entry>
<entry>
<fullUrl
value="https://claim.cgh.org.tw/iclaim/Practitioner/Practitioner-Wang"/>
<resource>
<Practitioner>
<id value="Practitioner-Wang"/>
<meta>
<profile
value="https://claim.cgh.org.tw/iclaim/StructureDefinition/practitioner-iclaim"/>
</meta>
<text>
<status value="generated"/>
<div xmlns="http://www.w3.org/1999/xhtml"><h3><b>健康照護服務提供人員基本資料</b></h3><p><b>識別碼型別</b>：Medical License number <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki">（ <a href="http://terminology.hl7.org/CodeSystem/v2-0203">Identifier Type Codes</a>#MD）</span><br/><b>員工編號（official）</b>：031933 （https://www.cgh.org.tw）</p><p><b>姓名（official）</b>：王建胃</p></div>
</text>
<identifier>
<use value="official"/>
<type>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/v2-0203"/>
<code value="MD"/>
</coding>
</type>
<system value="https://www.cgh.org.tw"/>
<value value="031933"/>
</identifier>
<name>
<use value="official"/>
<text value="王建胃"/>
</name>
</Practitioner>
</resource>
</entry>
<entry>
<fullUrl
value="https://claim.cgh.org.tw/iclaim/Practitioner/Practitioner-Ciou2"/>
<resource>
<Practitioner>
<id value="Practitioner-Ciou2"/>
<meta>
<profile
value="https://claim.cgh.org.tw/iclaim/StructureDefinition/practitioner-iclaim"/>
</meta>
<text>
<status value="generated"/>
<div xmlns="http://www.w3.org/1999/xhtml"><h3><b>健康照護服務提供人員基本資料</b></h3><p><b>姓名（official）</b>：邱榮二</p></div>
</text>
<name>
<use value="official"/>
<text value="邱榮二"/>
</name>
</Practitioner>
</resource>
</entry>
<entry>
<fullUrl
value="https://claim.cgh.org.tw/iclaim/Practitioner/Practitioner-Wang2"/>
<resource>
<Practitioner>
<id value="Practitioner-Wang2"/>
<meta>
<profile
value="https://claim.cgh.org.tw/iclaim/StructureDefinition/practitioner-iclaim"/>
</meta>
<text>
<status value="generated"/>
<div xmlns="http://www.w3.org/1999/xhtml"><h3><b>健康照護服務提供人員基本資料</b></h3><p><b>姓名（official）</b>：王二郎</p></div>
</text>
<name>
<use value="official"/>
<text value="王二郎"/>
</name>
</Practitioner>
</resource>
</entry>
<entry>
<fullUrl value="https://claim.cgh.org.tw/iclaim/Encounter/Encounter-C2"/>
<resource>
<Encounter>
<id value="Encounter-C2"/>
<meta>
<profile
value="https://claim.cgh.org.tw/iclaim/StructureDefinition/encounter-iclaim"/>
</meta>
<text>
<status value="generated"/>
<div xmlns="http://www.w3.org/1999/xhtml"><h3><b>就醫資料</b></h3><p><b>識別碼</b>：1286482 <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki">( <a href="https://www.cgh.org.tw">國泰醫療財團法人國泰綜合醫院</a>)</span></p><p><b>就醫現況</b>：finished <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki">( <a href="http://hl7.org/fhir/R4/codesystem-encounter-status.html">EncounterStatus</a>#finished)</span></p><p><b>就醫分類</b>：ambulatory <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki">( <a href="https://terminology.hl7.org/5.1.0/CodeSystem-v3-ActCode.html">ActEncounterCode</a>#AMB)</span></p><p><b>應診科別</b>：家醫科 <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki">( <a href="CodeSystem-nhi-department-values.html">Department</a>#01)</span></p><p><b>病人</b>：<a href="Patient-Patient-C2.html">Patient/Patient-C2</a> "康美女"</p><p><b>開單醫師</b>：<a href="PractitionerRole-PractitionerRole-rec2.html">PractitionerRole/PractitionerRole-rec2</a> "王二郎"</p><p><b>就醫的開始和結束時間</b>：2023-08-08 17:00:14-0500 --> 2023-08-08 18:00:14-0500</p><p><b>就醫天數</b>：1天 <span style="background: LightGoldenRodYellow">(Details: UCUM code d = 'd')</span></p></div>
</text>
<identifier>
<system value="https://www.cgh.org.tw"/>
<value value="1286482"/>
</identifier>
<status value="finished"/>
<class>
<system value="http://terminology.hl7.org/CodeSystem/v3-ActCode"/>
<code value="AMB"/>
</class>
<serviceType>
<coding>
<system
value="https://claim.cgh.org.tw/iclaim/CodeSystem/nhi-department-values"/>
<code value="01"/>
<display value="家醫科"/>
</coding>
</serviceType>
<subject>🔗
<reference value="Patient/Patient-C2"/>
</subject>
<participant>
<individual>🔗
<reference value="PractitionerRole/PractitionerRole-rec2"/>
</individual>
</participant>
<period>
<start value="2023-08-08T17:00:14-05:00"/>
<end value="2023-08-08T18:00:14-05:00"/>
</period>
<length>
<value value="1"/>
<unit value="days"/>
<system value="http://unitsofmeasure.org"/>
<code value="d"/>
</length>
</Encounter>
</resource>
</entry>
<entry>
<fullUrl
value="https://claim.cgh.org.tw/iclaim/PractitionerRole/PractitionerRole-pri2"/>
<resource>
<PractitionerRole>
<id value="PractitionerRole-pri2"/>
<meta>
<profile
value="https://claim.cgh.org.tw/iclaim/StructureDefinition/practitionerrole-iclaim"/>
</meta>
<text>
<status value="generated"/>
<div xmlns="http://www.w3.org/1999/xhtml"><h3><b>醫師角色基本資料</b></h3><p><b>健康照護服務提供者</b>：<a href="Practitioner-Practitioner-Wang.html">Practitioner/Practitioner-Wang</a> "王建胃"</p><p><b>角色</b>：主治醫師(Attending physician (occupation)) <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki">（ <a href="http://snomed.info/sct">SNOMED CT</a>#405279007）</span></p></div>
</text>
<practitioner>🔗
<reference value="Practitioner/Practitioner-Wang"/>
<display value="王建胃"/>
</practitioner>
<code>
<coding>
<system value="http://snomed.info/sct"/>
<code value="405279007"/>
<display value="Attending physician (occupation)"/>
</coding>
</code>
</PractitionerRole>
</resource>
</entry>
<entry>
<fullUrl
value="https://claim.cgh.org.tw/iclaim/PractitionerRole/PractitionerRole-res2"/>
<resource>
<PractitionerRole>
<id value="PractitionerRole-res2"/>
<meta>
<profile
value="https://claim.cgh.org.tw/iclaim/StructureDefinition/practitionerrole-iclaim"/>
</meta>
<text>
<status value="generated"/>
<div xmlns="http://www.w3.org/1999/xhtml"><h3><b>醫師角色基本資料</b></h3><p><b>健康照護服務提供者</b>：<a href="Practitioner-Practitioner-Ciou2.html">Practitioner/Practitioner-Ciou2</a> "邱榮二"</p><p><b>角色</b>：負責醫師（院長） <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki">（ <a href="CodeSystem-cathay-particulardiagnosis-values.html">醫事人員類別</a>#responsiblePhysician）</span></p></div>
</text>
<practitioner>🔗
<reference value="Practitioner/Practitioner-Ciou2"/>
<display value="邱榮二"/>
</practitioner>
<code>
<coding>
<system
value="https://claim.cgh.org.tw/iclaim/CodeSystem/cathay-healthprofessional-values"/>
<code value="responsiblePhysician"/>
</coding>
</code>
</PractitionerRole>
</resource>
</entry>
<entry>
<fullUrl
value="https://claim.cgh.org.tw/iclaim/PractitionerRole/PractitionerRole-rec2"/>
<resource>
<PractitionerRole>
<id value="PractitionerRole-rec2"/>
<meta>
<profile
value="https://claim.cgh.org.tw/iclaim/StructureDefinition/practitionerrole-iclaim"/>
</meta>
<text>
<status value="generated"/>
<div xmlns="http://www.w3.org/1999/xhtml"><h3><b>醫師角色基本資料</b></h3><p><b>健康照護服務提供者</b>：<a href="Practitioner-Practitioner-Wang2.html">Practitioner/Practitioner-Wang2</a> "王二郎"</p><p><b>角色</b>：開單醫師 <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki">（ <a href="CodeSystem-cathay-particulardiagnosis-values.html">醫事人員類別</a>#recordedPhysician</span></p></div>
</text>
<practitioner>🔗
<reference value="Practitioner/Practitioner-Wang2"/>
<display value="王二郎"/>
</practitioner>
<code>
<coding>
<system
value="https://claim.cgh.org.tw/iclaim/CodeSystem/cathay-healthprofessional-values"/>
<code value="recordedPhysician"/>
</coding>
</code>
</PractitionerRole>
</resource>
</entry>
</Bundle>