Release 5

This page is part of the FHIR Specification (v5.0.0: R5 - STU). This is the current published version. For a full list of available versions, see the Directory of published versions . Page versions: R5 R4B R4 R3 R2

Example Claim/100150 (JSON)

Financial Management Work GroupMaturity Level: N/AStandards Status: InformativeCompartments: Device, Encounter, Patient, Practitioner, RelatedPerson

Raw JSON (canonical form + also see JSON Format Specification)

Simple dental Claim

{
  "resourceType" : "Claim",
  "id" : "100150",
  "text" : {
    "status" : "generated",
    "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\">A human-readable rendering of the Oral Health Claim</div>"
  },
  "identifier" : [{
    "system" : "http://happyvalley.com/claim",
    "value" : "12345"
  }],
  "status" : "active",
  "type" : {
    "coding" : [{
      "system" : "http://terminology.hl7.org/CodeSystem/claim-type",
      "code" : "oral"
    }]
  },
  "use" : "claim",
  "patient" : {
    "reference" : "Patient/1"
  },
  "created" : "2014-08-16",
  "insurer" : {
    "reference" : "Organization/2"
  },
  "provider" : {
    "reference" : "Organization/1"
  },
  "priority" : {
    "coding" : [{
      "code" : "normal"
    }]
  },
  "payee" : {
    "type" : {
      "coding" : [{
        "code" : "provider"
      }]
    }
  },
  "careTeam" : [{
    "sequence" : 1,
    "provider" : {
      "reference" : "Practitioner/example"
    }
  }],
  "diagnosis" : [{
    "sequence" : 1,
    "diagnosisCodeableConcept" : {
      "coding" : [{
        "code" : "123456"
      }]
    }
  }],
  "insurance" : [{
    "sequence" : 1,
    "focal" : true,
    "identifier" : {
      "system" : "http://happyvalley.com/claim",
      "value" : "12345"
    },
    "coverage" : {
      "reference" : "Coverage/9876B1"
    }
  }],
  "item" : [{
    "sequence" : 1,
    "careTeamSequence" : [1],
    "productOrService" : {
      "coding" : [{
        "code" : "1200"
      }]
    },
    "servicedDate" : "2014-08-16",
    "unitPrice" : {
      "value" : 135.57,
      "currency" : "USD"
    },
    "net" : {
      "value" : 135.57,
      "currency" : "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.