This page is part of the FHIR Specification (v5.0.0-draft-final: Final QA Preview for R5 - see ballot notes). The current version which supercedes this version is 5.0.0. For a full list of available versions, see the Directory of published versions 
. Page versions: R5 R4B R4
Example Claim/MED-00050 (Turtle)
Raw Turtle (+ also see Turtle/RDF Format Specification)
Simple US Medical Surgery Claim
@prefix fhir: <http://hl7.org/fhir/> .
@prefix owl: <http://www.w3.org/2002/07/owl#> .
@prefix rdfs: <http://www.w3.org/2000/01/rdf-schema#> .
@prefix xsd: <http://www.w3.org/2001/XMLSchema#> .
# - resource -------------------------------------------------------------------
[a fhir:Claim ;
fhir:nodeRole fhir:treeRoot ;
fhir:id [ fhir:v "MED-00050"] ; #
fhir:text [
fhir:status [ fhir:v "generated" ] ;
fhir:div "<div xmlns=\"http://www.w3.org/1999/xhtml\">A human-readable rendering of a CMS 1500 Claim</div>"
] ; #
fhir:contained ( [
a fhir:Patient ;
fhir:id [ fhir:v "patient-1" ] ;
fhir:name ( [
fhir:use [ fhir:v "official" ] ;
fhir:family [ fhir:v "Ashcraft" ] ;
fhir:given ( [ fhir:v "Alvina" ] )
] ) ;
fhir:gender [ fhir:v "female" ] ;
fhir:birthDate [ fhir:v "1954-06-11"^^xsd:date ] ;
fhir:address ( [
fhir:use [ fhir:v "home" ] ;
fhir:line ( [ fhir:v "123 Main Street" ] ) ;
fhir:city [ fhir:v "Portland" ] ;
fhir:state [ fhir:v "OR" ] ;
fhir:postalCode [ fhir:v "97125" ] ;
fhir:country [ fhir:v "USA" ]
] )
] [
a fhir:Coverage ;
fhir:id [ fhir:v "coverage-1" ] ;
fhir:identifier ( [
fhir:system [ fhir:v "http://benefitsinc.com/certificate"^^xsd:anyURI ] ;
fhir:value [ fhir:v "10138556" ]
] ) ;
fhir:status [ fhir:v "active" ] ;
fhir:kind [ fhir:v "insurance" ] ;
fhir:type [
fhir:coding ( [
fhir:system [ fhir:v "http://terminology.hl7.org/CodeSystem/v3-ActCode"^^xsd:anyURI ] ;
fhir:code [ fhir:v "HIP" ] ;
fhir:display [ fhir:v "health insurance plan policy" ]
] )
] ;
fhir:subscriber [
fhir:reference [ fhir:v "#patient-1" ]
] ;
fhir:beneficiary [
fhir:reference [ fhir:v "#patient-1" ]
] ;
fhir:relationship [
fhir:coding ( [
fhir:code [ fhir:v "self" ]
] )
] ;
fhir:period [
fhir:start [ fhir:v "2015-01-01T00:00:00-07:00"^^xsd:dateTime ] ;
fhir:end [ fhir:v "2016-01-01T00:00:00-07:00"^^xsd:dateTime ]
] ;
fhir:insurer [
fhir:identifier [
fhir:system [ fhir:v "http://www.bindb.com/bin"^^xsd:anyURI ] ;
fhir:value [ fhir:v "123456" ]
] ;
fhir:display [ fhir:v "Humana Inc." ]
] ;
fhir:class ( [
fhir:type [
fhir:coding ( [
fhir:system [ fhir:v "http://terminology.hl7.org/CodeSystem/coverage-class"^^xsd:anyURI ] ;
fhir:code [ fhir:v "group" ]
] )
] ;
fhir:value [
fhir:value [ fhir:v "80902206" ]
]
] )
] ) ; #
fhir:identifier ( [
fhir:system [ fhir:v "http://CedarArmsMedicalCenter.com/claim"^^xsd:anyURI ] ;
fhir:value [ fhir:v "MED-00050" ]
] ) ; #
fhir:status [ fhir:v "active"] ; #
fhir:type [
fhir:coding ( [
fhir:system [ fhir:v "http://terminology.hl7.org/CodeSystem/claim-type"^^xsd:anyURI ] ;
fhir:code [ fhir:v "institutional" ]
] )
] ; #
fhir:subType [
fhir:coding ( [
fhir:system [ fhir:v "https://www.cms.gov/codes/billtype"^^xsd:anyURI ] ;
fhir:code [ fhir:v "831" ] ;
fhir:display [ fhir:v "Hospital Outpatient Surgery performed in an Ambulatory Surgical Center" ]
] )
] ; #
fhir:use [ fhir:v "claim"] ; #
fhir:patient [
fhir:reference [ fhir:v "#patient-1" ]
] ; #
fhir:created [ fhir:v "2015-10-16T00:00:00-07:00"^^xsd:dateTime] ; #
fhir:insurer [
fhir:identifier [
fhir:system [ fhir:v "http://www.bindb.com/bin"^^xsd:anyURI ] ;
fhir:value [ fhir:v "123456" ]
] ;
fhir:display [ fhir:v "Humana Inc." ]
] ; #
fhir:provider [
fhir:reference [ fhir:v "Organization/1" ]
] ; #
fhir:priority [
fhir:coding ( [
fhir:code [ fhir:v "normal" ]
] )
] ; #
fhir:payee [
fhir:type [
fhir:coding ( [
fhir:system [ fhir:v "http://terminology.hl7.org/CodeSystem/payeetype"^^xsd:anyURI ] ;
fhir:code [ fhir:v "provider" ]
] )
] ;
fhir:party [
fhir:reference [ fhir:v "Organization/1" ]
]
] ; #
fhir:careTeam ( [
fhir:sequence [ fhir:v "1"^^xsd:positiveInteger ] ;
fhir:provider [
fhir:reference [ fhir:v "Practitioner/example" ]
]
] ) ; #
fhir:supportingInfo ( [
fhir:sequence [ fhir:v "1"^^xsd:positiveInteger ] ;
fhir:category [
fhir:coding ( [
fhir:system [ fhir:v "http://terminology.hl7.org/CodeSystem/claiminformationcategory"^^xsd:anyURI ] ;
fhir:code [ fhir:v "hospitalized" ]
] )
] ;
fhir:timing [
a fhir:Period ;
fhir:start [ fhir:v "2015-10-01T00:00:00-07:00"^^xsd:dateTime ] ;
fhir:end [ fhir:v "2015-10-05T00:00:00-07:00"^^xsd:dateTime ]
]
] [
fhir:sequence [ fhir:v "2"^^xsd:positiveInteger ] ;
fhir:category [
fhir:coding ( [
fhir:system [ fhir:v "http://terminology.hl7.org/CodeSystem/claiminformationcategory"^^xsd:anyURI ] ;
fhir:code [ fhir:v "discharge" ]
] )
] ;
fhir:code [
fhir:coding ( [
fhir:system [ fhir:v "https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/SE0801.pdf"^^xsd:anyURI ] ;
fhir:code [ fhir:v "01" ] ;
fhir:display [ fhir:v "Discharge to Home or Self Care" ]
] )
]
] ) ; #
fhir:diagnosis ( [
fhir:sequence [ fhir:v "1"^^xsd:positiveInteger ] ;
fhir:diagnosis [
a fhir:CodeableConcept ;
fhir:coding ( [
fhir:system [ fhir:v "http://hl7.org/fhir/sid/icd-10-cm"^^xsd:anyURI ] ;
fhir:code [ fhir:v "M96.1" ] ;
fhir:display [ fhir:v "Postlaminectomy syndrome, not elsewhere classified" ]
] )
]
] [
fhir:sequence [ fhir:v "2"^^xsd:positiveInteger ] ;
fhir:diagnosis [
a fhir:CodeableConcept ;
fhir:coding ( [
fhir:system [ fhir:v "http://hl7.org/fhir/sid/icd-10-cm"^^xsd:anyURI ] ;
fhir:code [ fhir:v "G89.4" ] ;
fhir:display [ fhir:v "Chronic pain syndrome" ]
] )
]
] [
fhir:sequence [ fhir:v "3"^^xsd:positiveInteger ] ;
fhir:diagnosis [
a fhir:CodeableConcept ;
fhir:coding ( [
fhir:system [ fhir:v "http://hl7.org/fhir/sid/icd-10-cm"^^xsd:anyURI ] ;
fhir:code [ fhir:v "M53.88" ] ;
fhir:display [ fhir:v "Other specified dorsopathies, sacral and sacrococcygeal region" ]
] )
]
] [
fhir:sequence [ fhir:v "4"^^xsd:positiveInteger ] ;
fhir:diagnosis [
a fhir:CodeableConcept ;
fhir:coding ( [
fhir:system [ fhir:v "http://hl7.org/fhir/sid/icd-10-cm"^^xsd:anyURI ] ;
fhir:code [ fhir:v "M47.816" ] ;
fhir:display [ fhir:v "Spondylosis without myelopathy or radiculopathy, lumbar region" ]
] )
]
] ) ; #
fhir:insurance ( [
fhir:sequence [ fhir:v "1"^^xsd:positiveInteger ] ;
fhir:focal [ fhir:v "true"^^xsd:boolean ] ;
fhir:identifier [
fhir:system [ fhir:v "http://CedarArmsMedicalCenter.com/claim"^^xsd:anyURI ] ;
fhir:value [ fhir:v "MED-00050" ]
] ;
fhir:coverage [
fhir:reference [ fhir:v "#coverage-1" ]
]
] ) ; #
fhir:item ( [
fhir:sequence [ fhir:v "1"^^xsd:positiveInteger ] ;
fhir:careTeamSequence ( [ fhir:v "1"^^xsd:positiveInteger ] ) ;
fhir:diagnosisSequence ( [ fhir:v "2"^^xsd:positiveInteger ] [ fhir:v "4"^^xsd:positiveInteger ] ) ;
fhir:informationSequence ( [ fhir:v "1"^^xsd:positiveInteger ] ) ;
fhir:productOrService [
fhir:coding ( [
fhir:system [ fhir:v "http://www.ama-assn.org/go/cpt"^^xsd:anyURI ] ;
fhir:code [ fhir:v "62264" ] ;
fhir:display [ fhir:v "Surgical Procedures on the Spine and Spinal Cord" ]
] )
] ;
fhir:serviced [ fhir:v "2015-10-13"^^xsd:date ] ;
fhir:location [
a fhir:CodeableConcept ;
fhir:coding ( [
fhir:system [ fhir:v "https://www.cms.gov/medicare/coding/place-of-service-codes/place_of_service_code_set.html"^^xsd:anyURI ] ;
fhir:code [ fhir:v "24" ] ;
fhir:display [ fhir:v "Ambulatory Surgical Center" ]
] )
] ;
fhir:unitPrice [
fhir:value [ fhir:v "12500.00"^^xsd:decimal ] ;
fhir:currency [ fhir:v "USD" ]
] ;
fhir:net [
fhir:value [ fhir:v "12500.00"^^xsd:decimal ] ;
fhir:currency [ fhir:v "USD" ]
]
] ) ; #
fhir:total [
fhir:value [ fhir:v "12500.00"^^xsd:decimal ] ;
fhir:currency [ fhir:v "USD" ]
]] . #
# -------------------------------------------------------------------------------------
Usage note: every effort has been made to ensure that the
examples are correct and useful, but they are not a normative part
of the specification.
|
Propose a change
Financial