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 - JSON Representation

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    {
      "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 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\u00a0(use:\u00a0usual,\u00a0period:\u00a02001-05-06 --&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>"
      },
      "identifier" : [
        {
          "system" : "http://example.org/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" : [
          {
            "system" : "http://terminology.hl7.org/CodeSystem/processpriority",
            "code" : "normal"
          }
        ]
      },
      "prescription" : {
        🔗 "reference" : "MedicationRequest/example"
      },
      "payee" : {
        "type" : {
          "coding" : [
            {
              "system" : "http://terminology.hl7.org/CodeSystem/payeetype",
              "code" : "provider"
            }
          ]
        },
        "party" : {
          🔗 "reference" : "Practitioner/example"
        }
      },
      "careTeam" : [
        {
          "sequence" : 1,
          "provider" : {
            🔗 "reference" : "Practitioner/example"
          }
        }
      ],
      "diagnosis" : [
        {
          "sequence" : 1,
          "diagnosisCodeableConcept" : {
            "coding" : [
              {
                "system" : "http://hl7.org/fhir/sid/icd-10-cm",
                "code" : "H44.23"
              }
            ]
          }
        }
      ],
      "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"
              }
            }
          ]
        }
      ]
    }