This page is part of the Quality Improvement Core Framework (v5.0.0: STU5 (v5.0.0)) 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 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: Claim</b><a name="example"> </a></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">QICore Claim</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/5.0.0/CodeSystem-payeetype.html">Claim Payee Type Codes</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><h3>UnitPrices</h3><table class="grid"><tr><td>-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td>*</td><td>214.00</td><td>USD</td></tr></table><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><h3>UnitPrices</h3><table class="grid"><tr><td>-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td>*</td><td>100.00</td><td>USD</td></tr></table><h3>Nets</h3><table class="grid"><tr><td>-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td>*</td><td>100.00</td><td>USD</td></tr></table></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><h3>UnitPrices</h3><table class="grid"><tr><td>-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td>*</td><td>50.00</td><td>USD</td></tr></table><h3>Nets</h3><table class="grid"><tr><td>-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td>*</td><td>100.00</td><td>USD</td></tr></table></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><h3>UnitPrices</h3><table class="grid"><tr><td>-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td>*</td><td>200.00</td><td>USD</td></tr></table><p><b>factor</b>: 0.07</p><h3>Nets</h3><table class="grid"><tr><td>-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td>*</td><td>14.00</td><td>USD</td></tr></table></blockquote></blockquote></div>
</text>
<identifier>
<system value="http://happysight.com/claim"/>
<value value="6612346"/>
</identifier>
<status value="active"/>
<type>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/claim-type"/>
<code value="vision"/>
</coding>
</type>
<use value="claim"/>
<patient>
<reference value="Patient/example"/>
</patient>
<created value="2014-08-16"/>
<insurer>
<reference value="Organization/example"/>
</insurer>
<provider>
<reference value="Practitioner/example"/>
</provider>
<priority>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/processpriority"/>
<code value="normal"/>
</coding>
</priority>
<prescription>
<reference value="MedicationRequest/example"/>
</prescription>
<payee>
<type>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/payeetype"/>
<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>
<system value="http://example.org/diagnosis/CodeSystem"/>
<code value="654321"/>
</coding>
</diagnosisCodeableConcept>
</diagnosis>
<insurance>
<sequence value="1"/>
<focal value="true"/>
<coverage>
<reference value="Coverage/example"/>
</coverage>
</insurance>
<item>
<sequence value="1"/>
<careTeamSequence value="1"/>
<productOrService>
<coding>
<system value="http://example.org/fhir/CodeSystem/ex-visionservice"/>
<code value="glasses"/>
</coding>
</productOrService>
<servicedDate value="2014-08-16"/>
<unitPrice>
<value value="214.00"/>
<currency value="USD"/>
</unitPrice>
<detail>
<sequence value="1"/>
<productOrService>
<coding>
<system
value="http://example.org/fhir/CodeSystem/ex-visionservice"/>
<code value="frame"/>
</coding>
</productOrService>
<unitPrice>
<value value="100.00"/>
<currency value="USD"/>
</unitPrice>
<net>
<value value="100.00"/>
<currency value="USD"/>
</net>
</detail>
<detail>
<sequence value="2"/>
<productOrService>
<coding>
<system
value="http://example.org/fhir/CodeSystem/ex-visionservice"/>
<code value="lens"/>
</coding>
</productOrService>
<quantity>
<value value="2"/>
</quantity>
<unitPrice>
<value value="50.00"/>
<currency value="USD"/>
</unitPrice>
<net>
<value value="100.00"/>
<currency value="USD"/>
</net>
</detail>
<detail>
<sequence value="3"/>
<productOrService>
<coding>
<system
value="http://example.org/fhir/CodeSystem/ex-visionservice"/>
<code value="fst"/>
</coding>
</productOrService>
<unitPrice>
<value value="200.00"/>
<currency value="USD"/>
</unitPrice>
<factor value="0.07"/>
<net>
<value value="14.00"/>
<currency value="USD"/>
</net>
</detail>
</item>
</Claim>
IG © 2019+ http://www.hl7.org/Special/committees/cqi/index.cfm. Package hl7.fhir.us.qicore#5.0.0 based on FHIR 4.0.1. Generated 2023-04-04
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