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Financial Management Work Group | Maturity Level: N/A | Standards Status: Informative | Compartments: Device, Encounter, Patient, Practitioner, RelatedPerson |
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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.
FHIR ®© HL7.org 2011+. FHIR R5 hl7.fhir.core#5.0.0 generated on Sun, Mar 26, 2023 15:24+1100.
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