QI-Core Implementation Guide
7.0.2 - STU 7

QI-Core Implementation Guide - Downloaded Version 7.0.2 See the Directory of published versions

## Example Claim: Claim example

Page standards status: Informative

Profile: QICore Claim

identifier: `http://example.org/claim`/6612346

status: Active

type: Vision

use: Claim

patient: Jim Chalmers Male, DoB: 1974-12-25 ( Medical record number (use: usual, period: 2001-05-06 --> (ongoing)))

created: 2014-08-16

insurer: Organization Health Level Seven International

provider: Practitioner Adam Careful

priority: Normal

prescription: MedicationRequest: status = active; intent = order; medication[x] = ->Medication alemtuzumab 10 MG/ML [Lemtrada]; authoredOn = 2015-03-25 19:32:52-0500

### Payees

- | Type | Party
* | Provider | Practitioner Adam Careful

### CareTeams

- | Sequence | Provider
* | 1 | Practitioner Adam Careful

### Diagnoses

- | Sequence | Diagnosis[x]
* | 1 | Degenerative myopia, bilateral

### Insurances

- | Sequence | Focal | Coverage
* | 1 | true | Coverage: identifier = Member Number; status = active; type = Other Private Insurance; dependent = 0; relationship = Self; period = 2011-05-23 --> 2012-05-23; order = 9

> item

> sequence: 1

> careTeamSequence: 1

> productOrService: glasses

> serviced: 2014-08-16

> ### UnitPrices

> - | Value | Currency
> * | 214.00 | United States dollar

> > detail

> > sequence: 1

> > productOrService: frame

> > ### UnitPrices

> > - | Value | Currency
> > * | 100.00 | United States dollar

> > ### Nets

> > - | Value | Currency
> > * | 100.00 | United States dollar

> > detail

> > sequence: 2

> > productOrService: lens

> > quantity: 2

> > ### UnitPrices

> > - | Value | Currency
> > * | 50.00 | United States dollar

> > ### Nets

> > - | Value | Currency
> > * | 100.00 | United States dollar

> > detail

> > sequence: 3

> > productOrService: fst

> > ### UnitPrices

> > - | Value | Currency
> > * | 200.00 | United States dollar

> > factor: 0.07

> > ### Nets

> > - | Value | Currency
> > * | 14.00 | United States dollar