QI-Core Implementation Guide
5.0.0-ballot - STU Ballot US

This page is part of the Quality Improvement Core Framework (v5.0.0-ballot: STU 5 Ballot 1) based on FHIR R4. The current version which supercedes this version is 4.1.1. For a full list of available versions, see the Directory of published versions

: Claim example - JSON Representation

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{
  "resourceType" : "Claim",
  "id" : "example",
  "meta" : {
    "profile" : [
      "http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-claim"
    ]
  },
  "text" : {
    "status" : "generated",
    "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p><b>Generated Narrative: Claim</b></p><div style=\"display: inline-block; background-color: #d9e0e7; padding: 6px; margin: 4px; border: 1px solid #8da1b4; border-radius: 5px; line-height: 60%\"><p style=\"margin-bottom: 0px\">Resource Claim \"example\" </p><p style=\"margin-bottom: 0px\">Profile: <a href=\"StructureDefinition-qicore-claim.html\">QICoreClaim</a></p></div><p><b>identifier</b>: id: 6612346</p><p><b>status</b>: active</p><p><b>type</b>: Vision <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"http://terminology.hl7.org/3.1.0/CodeSystem-claim-type.html\">Claim Type Codes</a>#vision)</span></p><p><b>use</b>: claim</p><p><b>patient</b>: <a href=\"Patient-example.html\">Patient/example</a> \" CHALMERS\"</p><p><b>created</b>: 2014-08-16</p><p><b>insurer</b>: <a href=\"Organization-example.html\">Organization/example</a> \"Health Level Seven International\"</p><p><b>provider</b>: <a href=\"Practitioner-example.html\">Practitioner/example</a> \" CAREFUL\"</p><p><b>priority</b>: Normal <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"http://terminology.hl7.org/3.1.0/CodeSystem-processpriority.html\">Process Priority Codes</a>#normal)</span></p><p><b>prescription</b>: <a href=\"MedicationRequest-example.html\">MedicationRequest/example</a></p><h3>Payees</h3><table class=\"grid\"><tr><td>-</td><td><b>Type</b></td><td><b>Party</b></td></tr><tr><td>*</td><td>Provider <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"http://terminology.hl7.org/3.1.0/CodeSystem-payeetype.html\">ClaimPayeeTypeCodes</a>#provider)</span></td><td><a href=\"Practitioner-example.html\">Practitioner/example</a> \" CAREFUL\"</td></tr></table><h3>CareTeams</h3><table class=\"grid\"><tr><td>-</td><td><b>Sequence</b></td><td><b>Provider</b></td></tr><tr><td>*</td><td>1</td><td><a href=\"Practitioner-example.html\">Practitioner/example</a> \" CAREFUL\"</td></tr></table><h3>Diagnoses</h3><table class=\"grid\"><tr><td>-</td><td><b>Sequence</b></td><td><b>Diagnosis[x]</b></td></tr><tr><td>*</td><td>1</td><td>654321 <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (CodeSystem#654321)</span></td></tr></table><h3>Insurances</h3><table class=\"grid\"><tr><td>-</td><td><b>Sequence</b></td><td><b>Focal</b></td><td><b>Coverage</b></td></tr><tr><td>*</td><td>1</td><td>true</td><td><a href=\"Coverage-example.html\">Coverage/example</a></td></tr></table><blockquote><p><b>item</b></p><p><b>sequence</b>: 1</p><p><b>careTeamSequence</b>: 1</p><p><b>productOrService</b>: glasses <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (ex-visionservice#glasses)</span></p><p><b>serviced</b>: 2014-08-16</p><blockquote><p><b>detail</b></p><p><b>sequence</b>: 1</p><p><b>productOrService</b>: frame <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (ex-visionservice#frame)</span></p></blockquote><blockquote><p><b>detail</b></p><p><b>sequence</b>: 2</p><p><b>productOrService</b>: lens <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (ex-visionservice#lens)</span></p><p><b>quantity</b>: 2</p></blockquote><blockquote><p><b>detail</b></p><p><b>sequence</b>: 3</p><p><b>productOrService</b>: fst <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (ex-visionservice#fst)</span></p><p><b>factor</b>: 0.07</p></blockquote></blockquote></div>"
  },
  "identifier" : [
    {
      "system" : "http://happysight.com/claim",
      "value" : "6612346"
    }
  ],
  "status" : "active",
  "type" : {
    "coding" : [
      {
        "system" : "http://terminology.hl7.org/CodeSystem/claim-type",
        "code" : "vision"
      }
    ]
  },
  "use" : "claim",
  "patient" : {
    "reference" : "Patient/example"
  },
  "created" : "2014-08-16",
  "insurer" : {
    "reference" : "Organization/example"
  },
  "provider" : {
    "reference" : "Practitioner/example"
  },
  "priority" : {
    "coding" : [
      {
        "system" : "http://terminology.hl7.org/CodeSystem/processpriority",
        "code" : "normal"
      }
    ]
  },
  "prescription" : {
    "reference" : "MedicationRequest/example"
  },
  "payee" : {
    "type" : {
      "coding" : [
        {
          "system" : "http://terminology.hl7.org/CodeSystem/payeetype",
          "code" : "provider"
        }
      ]
    },
    "party" : {
      "reference" : "Practitioner/example"
    }
  },
  "careTeam" : [
    {
      "sequence" : 1,
      "provider" : {
        "reference" : "Practitioner/example"
      }
    }
  ],
  "diagnosis" : [
    {
      "sequence" : 1,
      "diagnosisCodeableConcept" : {
        "coding" : [
          {
            "system" : "http://example.org/diagnosis/CodeSystem",
            "code" : "654321"
          }
        ]
      }
    }
  ],
  "insurance" : [
    {
      "sequence" : 1,
      "focal" : true,
      "coverage" : {
        "reference" : "Coverage/example"
      }
    }
  ],
  "item" : [
    {
      "sequence" : 1,
      "careTeamSequence" : [
        1
      ],
      "productOrService" : {
        "coding" : [
          {
            "system" : "http://example.org/fhir/CodeSystem/ex-visionservice",
            "code" : "glasses"
          }
        ]
      },
      "servicedDate" : "2014-08-16",
      "unitPrice" : {
        "value" : 214.00,
        "currency" : "USD"
      },
      "detail" : [
        {
          "sequence" : 1,
          "productOrService" : {
            "coding" : [
              {
                "system" : "http://example.org/fhir/CodeSystem/ex-visionservice",
                "code" : "frame"
              }
            ]
          },
          "unitPrice" : {
            "value" : 100.00,
            "currency" : "USD"
          },
          "net" : {
            "value" : 100.00,
            "currency" : "USD"
          }
        },
        {
          "sequence" : 2,
          "productOrService" : {
            "coding" : [
              {
                "system" : "http://example.org/fhir/CodeSystem/ex-visionservice",
                "code" : "lens"
              }
            ]
          },
          "quantity" : {
            "value" : 2
          },
          "unitPrice" : {
            "value" : 50.00,
            "currency" : "USD"
          },
          "net" : {
            "value" : 100.00,
            "currency" : "USD"
          }
        },
        {
          "sequence" : 3,
          "productOrService" : {
            "coding" : [
              {
                "system" : "http://example.org/fhir/CodeSystem/ex-visionservice",
                "code" : "fst"
              }
            ]
          },
          "unitPrice" : {
            "value" : 200.00,
            "currency" : "USD"
          },
          "factor" : 0.07,
          "net" : {
            "value" : 14.00,
            "currency" : "USD"
          }
        }
      ]
    }
  ]
}