This page is part of the Quality Improvement Core Framework (v2.0.0: STU 2) based on FHIR (HL7® FHIR® Standard) R3. The current version which supersedes this version is 7.0.1. For a full list of available versions, see the Directory of published versions

Example: Claim-qicore-claim-example

Formats: XML, JSON, Turtle

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