QI-Core Implementation Guide: STU 3.2 (v3.2.0 for FHIR 3.0.1)

This page is part of the Quality Improvement Core Framework (v3.2.0: STU 3) 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

Claim example

Formats: Narrative, XML, JSON, Turtle

Raw xml 


<Claim xmlns="http://hl7.org/fhir">
  <id value="example"/>
  <meta>
    <profile
             value="http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-claim"/>
  </meta>
  <text>
    <status value="generated"/>
    <div xmlns="http://www.w3.org/1999/xhtml"><p><b>Generated Narrative with Details</b></p><p><b>id</b>: example</p><p><b>meta</b>: </p><p><b>identifier</b>: 6612346</p><p><b>status</b>: active</p><p><b>type</b>: Vision <span style="background: LightGoldenRodYellow">(Details : {http://hl7.org/fhir/ex-claimtype code 'vision' = 'Vision)</span></p><p><b>use</b>: complete</p><p><b>patient</b>: <a href="Patient-example.html">Generated Summary: id: example; Medical record number = 12345 (USUAL); active; Peter James Chalmers (OFFICIAL), Jim Chalmers , Peter James Windsor (MAIDEN); -unknown-(HOME), ph: (03) 5555 6473(WORK), ph: (03) 3410 5613(MOBILE), ph: (03) 5555 8834(OLD); gender: male; birthDate: 25/12/1974; </a></p><p><b>created</b>: 16/08/2014</p><p><b>insurer</b>: <a href="Organization-example.html">Generated Summary: id: example; ??; active; <span title="Codes: {http://hl7.org/fhir/organization-type team}">Organizational team</span>; name: Health Level Seven International; ph: (+1) 734-677-7777, fax: (+1) 734-677-6622, hq@HL7.org</a></p><p><b>provider</b>: <a href="Practitioner-example.html">Generated Summary: id: example; 23; active; Adam Careful </a></p><p><b>organization</b>: <a href="Organization-example.html">Generated Summary: id: example; ??; active; <span title="Codes: {http://hl7.org/fhir/organization-type team}">Organizational team</span>; name: Health Level Seven International; ph: (+1) 734-677-7777, fax: (+1) 734-677-6622, hq@HL7.org</a></p><p><b>priority</b>: normal <span style="background: LightGoldenRodYellow">(Details : {[not stated] code 'normal' = 'normal)</span></p><p><b>prescription</b>: <a href="MedicationRequest-example.html">Generated Summary: id: example; status: active; intent: order; ????; authoredOn: 26/03/2015 11:32:52 AM; </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">(Details : {[not stated] code 'provider' = 'provider)</span></td><td><a href="Practitioner-example.html">Generated Summary: id: example; 23; active; Adam Careful </a></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">Generated Summary: id: example; 23; active; Adam Careful </a></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">(Details : {[not stated] code '654321' = '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">Generated Summary: id: example; 12345; status: active; <span title="Codes: {http://hl7.org/fhir/v3/ActCode EHCPOL}">extended healthcare</span>; <span title="Codes: ">self</span>; period: 23/05/2011 12:00:00 AM --&gt; 23/05/2012 12:00:00 AM; dependent: 0; sequence: 9</a></td></tr></table><blockquote><p><b>item</b></p><p><b>sequence</b>: 1</p><p><b>careTeamLinkId</b>: 1</p><p><b>service</b>: glasses <span style="background: LightGoldenRodYellow">(Details : {http://example.org/fhir/CodeSystem/ex-visionservice code 'glasses' = 'glasses)</span></p><p><b>serviced</b>: 16/08/2014</p><p><b>unitPrice</b>: </p><p><b>net</b>: </p><blockquote><p><b>detail</b></p><p><b>sequence</b>: 1</p><p><b>service</b>: frame <span style="background: LightGoldenRodYellow">(Details : {http://example.org/fhir/CodeSystem/ex-visionservice code 'frame' = 'frame)</span></p><p><b>unitPrice</b>: </p><p><b>net</b>: </p></blockquote><blockquote><p><b>detail</b></p><p><b>sequence</b>: 2</p><p><b>service</b>: lens <span style="background: LightGoldenRodYellow">(Details : {http://example.org/fhir/CodeSystem/ex-visionservice code 'lens' = 'lens)</span></p><p><b>quantity</b>: 2</p><p><b>unitPrice</b>: </p><p><b>net</b>: </p></blockquote><blockquote><p><b>detail</b></p><p><b>sequence</b>: 3</p><p><b>service</b>: fst <span style="background: LightGoldenRodYellow">(Details : {http://example.org/fhir/CodeSystem/ex-visionservice code 'fst' = 'fst)</span></p><p><b>unitPrice</b>: </p><p><b>factor</b>: 0.07</p><p><b>net</b>: </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/example"/>
  </patient>
  <created value="2014-08-16"/>
  <insurer>
    <reference value="Organization/example"/>
  </insurer>
  <provider>
    <reference value="Practitioner/example"/>
  </provider>
  <organization>
    <reference value="Organization/example"/>
  </organization>
  <priority>
    <coding>
      <code value="normal"/>
    </coding>
  </priority>
  <prescription>
    <reference value="MedicationRequest/example"/>
  </prescription>
  <payee>
    <type>
      <coding>
        <code value="provider"/>
      </coding>
    </type>
    <party>
      <reference value="Practitioner/example"/>
    </party>
  </payee>
  <careTeam>
    <sequence value="1"/>
    <provider>
      <reference value="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/example"/>
    </coverage>
  </insurance>
  <item>
    <sequence value="1"/>
    <careTeamLinkId value="1"/>
    <service>
      <coding>
        <system value="http://example.org/fhir/CodeSystem/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://example.org/fhir/CodeSystem/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://example.org/fhir/CodeSystem/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://example.org/fhir/CodeSystem/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>