QI-Core Implementation Guide
5.0.0 - STU5 United States of America flag

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 example - XML Representation

Raw xml | Download



<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 &quot;example&quot; </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> &quot; CHALMERS&quot;</p><p><b>created</b>: 2014-08-16</p><p><b>insurer</b>: <a href="Organization-example.html">Organization/example</a> &quot;Health Level Seven International&quot;</p><p><b>provider</b>: <a href="Practitioner-example.html">Practitioner/example</a> &quot; CAREFUL&quot;</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> &quot; CAREFUL&quot;</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> &quot; CAREFUL&quot;</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>