Claim/example

Formats: Narrative, XML, JSON, Turtle

Raw json

{
  "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 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://terminology.hl7.org/CodeSystem/claim-type code 'vision' = 'Vision)</span></p><p><b>use</b>: claim</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); ph: (03) 5555 6473(WORK), ph: (03) 3410 5613(MOBILE), ph: (03) 5555 8834(OLD); gender: male; birthDate: 1974-12-25; </a></p><p><b>created</b>: Aug 16, 2014 12:00:00 AM</p><p><b>insurer</b>: <a href=\"Organization-example.html\">Generated Summary: id: example; ??; active; <span title=\"Codes: {http://terminology.hl7.org/CodeSystem/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>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: Mar 26, 2015 12:32:52 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: {urn:oid:2.16.840.1.113883.3.221.5 59}\">Other Private Insurance</span>; dependent: 0; <span title=\"Codes: \">self</span>; period: May 23, 2011 12:00:00 AM --&gt; May 23, 2012 12:00:00 AM; 9</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\">(Details : {http://example.org/fhir/CodeSystem/ex-visionservice code 'glasses' = 'glasses)</span></p><p><b>serviced</b>: 2014-08-16</p><p><b>unitPrice</b>: </p><blockquote><p><b>detail</b></p><p><b>sequence</b>: 1</p><p><b>productOrService</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>productOrService</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>productOrService</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>"
  },
  "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" : [
      {
        "code" : "normal"
      }
    ]
  },
  "prescription" : {
    "reference" : "MedicationRequest/example"
  },
  "payee" : {
    "type" : {
      "coding" : [
        {
          "code" : "provider"
        }
      ]
    },
    "party" : {
      "reference" : "Practitioner/example"
    }
  },
  "careTeam" : [
    {
      "sequence" : 1,
      "provider" : {
        "reference" : "Practitioner/example"
      }
    }
  ],
  "diagnosis" : [
    {
      "sequence" : 1,
      "diagnosisCodeableConcept" : {
        "coding" : [
          {
            "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"
          }
        }
      ]
    }
  ]
}