This page is part of the Quality Improvement Core Framework (v2.1.0: STU 3 Ballot 1) based on FHIR R3. The current version which supercedes this version is 4.1.1. For a full list of available versions, see the Directory of published versions

Example: Claim-qicore-claim-example

Formats: XML, JSON, Turtle

<Claim xmlns="http://hl7.org/fhir">
  <id value="qicore-claim-example"/>
  <text>
    <status value="generated"/>
    <div xmlns="http://www.w3.org/1999/xhtml">
      <p>
        <strong>id</strong>: example            
      </p>
      <p>
        <strong>identifier</strong>: 6612346            
      </p>
      <p>
        <strong>type</strong>: vision      
      </p>
      <p>
        <strong>use</strong>: complete      
      </p>
      <p>
        <strong>patient</strong>:                 
        <a href="Patient-qicore-patient-example.html">Patient/example</a>
      </p>
      <p>
        <strong>insurer</strong>:                 
        <a href="Organization-qicore-organization-example.html">Organization/example</a>
      </p>
      <p>
        <strong>organization</strong>:                 
        <a href="Organization-qicore-organization-example.html">Organization/example</a>
      </p>
      <p>
        <strong>priority</strong>: normal      
      </p>
      <p>
        <strong>prescription</strong>:                 
        <a href="MedicationRequest-qicore-medicationrequest-example">MedicationRequest/example</a>
      </p>
      <p>
        <strong>payee</strong>:
        <a href="Practitioner-qicore-practitioner-example">Practitioner/example</a>
      </p>
      <p>
        <strong>careTeam</strong>:
        <a href="Practitioner-qicore-practitioner-example">Practitioner/example</a>
      </p>
      <p>
        <strong>diagnosis</strong>: 654321      
      </p>
      <p>
        <strong>insurance</strong>:                 
        <a href="Coverage-qicore-converage-example">Coverage/example</a>
      </p>
      <blockquote>
        <p>
          <strong>item</strong>
        </p>
        <p>
          <strong>service</strong>: glasses        
        </p>
        <p>
          <strong>unitPrice</strong>: 214.00        
        </p>
        <p>
          <strong>net</strong>: 214.00        
        </p>
        <blockquote>
          <p><strong>detail 1</strong></p>
          <p>
            <strong>service</strong>: frame          
          </p>
          <p>
            <strong>unitPrice</strong>: 100.00          
          </p>
          <p>
            <strong>net</strong>: 100.00          
          </p>
        </blockquote>
        <blockquote>
          <p><strong>detail 2</strong></p>
          <p>
            <strong>service</strong>: lens          
          </p>
          <p>
            <strong>unitPrice</strong>: 50.00          
          </p>
          <p>
            <strong>net</strong>: 100.00          
          </p>
        </blockquote>
        <blockquote>
          <p><strong>detail 3</strong></p>
          <p>
            <strong>service</strong>: fst          
          </p>
          <p>
            <strong>unitPrice</strong>: 200.00          
          </p>
          <p>
            <strong>factor</strong>: 0.07          
          </p>
          <p>
            <strong>net</strong>: 14.00          
          </p>
        </blockquote>
      </blockquote>
    </div>
  </text>
  <identifier>
    <system value="http://happysight.com/claim"/>
    <value value="6612346"/>
  </identifier>
  <status value="active"/>
  <type>
    <coding>
      <system value="http://hl7.org/fhir/ex-claimtype"/>
      <code value="vision"/>
    </coding>
  </type>
  <use value="complete"/>
  <patient>
    <reference value="Patient/qicore-patient-example"/>
  </patient>
  <created value="2014-08-16"/>
  <insurer>
    <reference value="Organization/qicore-organization-example"/>
  </insurer>
  <organization>
    <reference value="Organization/qicore-organization-example"/>
  </organization>
  <priority>
    <coding>
      <code value="normal"/>
    </coding>
  </priority>
  <prescription>
    <reference value="MedicationRequest/qicore-medicationrequest-example"/>
  </prescription>
  <payee>
    <type>
      <coding>
        <code value="provider"/>
      </coding>
    </type>
    <party>
      <reference value="Practitioner/qicore-practitioner-example"/>
    </party>
  </payee>
  <careTeam>
    <sequence value="1"/>
    <provider>
      <reference value="Practitioner/qicore-practitioner-example"/>
    </provider>
  </careTeam>
  <diagnosis>
    <sequence value="1"/>
    <diagnosisCodeableConcept>
      <coding>
        <code value="654321"/>
      </coding>
    </diagnosisCodeableConcept>
  </diagnosis>
  <insurance>
    <sequence value="1"/>
    <focal value="true"/>
    <coverage>
      <reference value="Coverage/qicore-coverage-example"/>
    </coverage>
  </insurance>
  <item>
    <sequence value="1"/>
    <careTeamLinkId value="1"/>
    <service>
      <coding>
        <system value="http://hl7.org/fhir/ex-visionservice"/>
        <code value="glasses"/>
      </coding>
    </service>
    <servicedDate value="2014-08-16"/>
    <unitPrice>
      <value value="214.00"/>
      <system value="urn:iso:std:iso:4217"/>
      <code value="USD"/>
    </unitPrice>
    <net>
      <value value="214.00"/>
      <system value="urn:iso:std:iso:4217"/>
      <code value="USD"/>
    </net>
    <detail>
      <sequence value="1"/>
      <service>
        <coding>
          <system value="http://hl7.org/fhir/ex-visionservice"/>
          <code value="frame"/>
        </coding>
      </service>
      <unitPrice>
        <value value="100.00"/>
        <system value="urn:iso:std:iso:4217"/>
        <code value="USD"/>
      </unitPrice>
      <net>
        <value value="100.00"/>
        <system value="urn:iso:std:iso:4217"/>
        <code value="USD"/>
      </net>
    </detail>
    <detail>
      <sequence value="2"/>
      <service>
        <coding>
          <system value="http://hl7.org/fhir/ex-visionservice"/>
          <code value="lens"/>
        </coding>
      </service>
      <quantity>
        <value value="2"/>
      </quantity>
      <unitPrice>
        <value value="50.00"/>
        <system value="urn:iso:std:iso:4217"/>
        <code value="USD"/>
      </unitPrice>
      <net>
        <value value="100.00"/>
        <system value="urn:iso:std:iso:4217"/>
        <code value="USD"/>
      </net>
    </detail>
    <detail>
      <sequence value="3"/>
      <service>
        <coding>
          <system value="http://hl7.org/fhir/ex-visionservice"/>
          <code value="fst"/>
        </coding>
      </service>
      <unitPrice>
        <value value="200.00"/>
        <system value="urn:iso:std:iso:4217"/>
        <code value="USD"/>
      </unitPrice>
      <factor value="0.07"/>
      <net>
        <value value="14.00"/>
        <system value="urn:iso:std:iso:4217"/>
        <code value="USD"/>
      </net>
    </detail>
  </item>
</Claim>