QI-Core Implementation Guide
7.0.2 - STU 7

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

## : Claim example - XML Representation

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    <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 class="res-header-id"><b>Generated Narrative: Claim example</b></p><a name="example"> </a><a name="hcexample"> </a><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"/><p style="margin-bottom: 0px">Profile: <a href="StructureDefinition-qicore-claim.html">QICore Claim</a></p></div><p><b>identifier</b>: <code>http://example.org/claim</code>/6612346</p><p><b>status</b>: Active</p><p><b>type</b>: <span title="Codes:{http://terminology.hl7.org/CodeSystem/claim-type vision}">Vision</span></p><p><b>use</b>: Claim</p><p><b>patient</b>: <a href="Patient-example.html">Jim Chalmers  Male, DoB: 1974-12-25 ( Medical record number (use: usual, period: 2001-05-06 --&gt; (ongoing)))</a></p><p><b>created</b>: 2014-08-16</p><p><b>insurer</b>: <a href="Organization-example.html">Organization Health Level Seven International</a></p><p><b>provider</b>: <a href="Practitioner-example.html">Practitioner Adam Careful </a></p><p><b>priority</b>: <span title="Codes:{http://terminology.hl7.org/CodeSystem/processpriority normal}">Normal</span></p><p><b>prescription</b>: <a href="MedicationRequest-example.html">MedicationRequest: status = active; intent = order; medication[x] = -&gt;Medication alemtuzumab 10 MG/ML [Lemtrada]; authoredOn = 2015-03-25 19:32:52-0500</a></p><h3>Payees</h3><table class="grid"><tr><td style="display: none">-</td><td><b>Type</b></td><td><b>Party</b></td></tr><tr><td style="display: none">*</td><td><span title="Codes:{http://terminology.hl7.org/CodeSystem/payeetype provider}">Provider</span></td><td><a href="Practitioner-example.html">Practitioner Adam Careful </a></td></tr></table><h3>CareTeams</h3><table class="grid"><tr><td style="display: none">-</td><td><b>Sequence</b></td><td><b>Provider</b></td></tr><tr><td style="display: none">*</td><td>1</td><td><a href="Practitioner-example.html">Practitioner Adam Careful </a></td></tr></table><h3>Diagnoses</h3><table class="grid"><tr><td style="display: none">-</td><td><b>Sequence</b></td><td><b>Diagnosis[x]</b></td></tr><tr><td style="display: none">*</td><td>1</td><td><span title="Codes:{http://hl7.org/fhir/sid/icd-10-cm H44.23}">Degenerative myopia, bilateral</span></td></tr></table><h3>Insurances</h3><table class="grid"><tr><td style="display: none">-</td><td><b>Sequence</b></td><td><b>Focal</b></td><td><b>Coverage</b></td></tr><tr><td style="display: none">*</td><td>1</td><td>true</td><td><a href="Coverage-example.html">Coverage: identifier = Member Number; status = active; type = Other Private Insurance; dependent = 0; relationship = Self; period = 2011-05-23 --&gt; 2012-05-23; order = 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>: <span title="Codes:{http://example.org/fhir/CodeSystem/ex-visionservice glasses}">glasses</span></p><p><b>serviced</b>: 2014-08-16</p><h3>UnitPrices</h3><table class="grid"><tr><td style="display: none">-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td style="display: none">*</td><td>214.00</td><td>United States dollar</td></tr></table><blockquote><p><b>detail</b></p><p><b>sequence</b>: 1</p><p><b>productOrService</b>: <span title="Codes:{http://example.org/fhir/CodeSystem/ex-visionservice frame}">frame</span></p><h3>UnitPrices</h3><table class="grid"><tr><td style="display: none">-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td style="display: none">*</td><td>100.00</td><td>United States dollar</td></tr></table><h3>Nets</h3><table class="grid"><tr><td style="display: none">-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td style="display: none">*</td><td>100.00</td><td>United States dollar</td></tr></table></blockquote><blockquote><p><b>detail</b></p><p><b>sequence</b>: 2</p><p><b>productOrService</b>: <span title="Codes:{http://example.org/fhir/CodeSystem/ex-visionservice lens}">lens</span></p><p><b>quantity</b>: 2</p><h3>UnitPrices</h3><table class="grid"><tr><td style="display: none">-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td style="display: none">*</td><td>50.00</td><td>United States dollar</td></tr></table><h3>Nets</h3><table class="grid"><tr><td style="display: none">-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td style="display: none">*</td><td>100.00</td><td>United States dollar</td></tr></table></blockquote><blockquote><p><b>detail</b></p><p><b>sequence</b>: 3</p><p><b>productOrService</b>: <span title="Codes:{http://example.org/fhir/CodeSystem/ex-visionservice fst}">fst</span></p><h3>UnitPrices</h3><table class="grid"><tr><td style="display: none">-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td style="display: none">*</td><td>200.00</td><td>United States dollar</td></tr></table><p><b>factor</b>: 0.07</p><h3>Nets</h3><table class="grid"><tr><td style="display: none">-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td style="display: none">*</td><td>14.00</td><td>United States dollar</td></tr></table></blockquote></blockquote></div>
      </text>
      <identifier>
        <system value="http://example.org/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://hl7.org/fhir/sid/icd-10-cm"/>
            <code value="H44.23"/>
          </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>