Release 5

This page is part of the FHIR Specification (v5.0.0: R5 - STU). This is the current published version. For a full list of available versions, see the Directory of published versions . Page versions: R5 R4B R4

Example Claim/MED-00050 (Turtle)

Financial Management Work GroupMaturity Level: N/AStandards Status: InformativeCompartments: Device, Encounter, Patient, Practitioner, RelatedPerson

Raw Turtle (+ also see Turtle/RDF Format Specification)

Simple US Medical Surgery Claim

@prefix fhir: <http://hl7.org/fhir/> .
@prefix owl: <http://www.w3.org/2002/07/owl#> .
@prefix rdfs: <http://www.w3.org/2000/01/rdf-schema#> .
@prefix xsd: <http://www.w3.org/2001/XMLSchema#> .

# - resource -------------------------------------------------------------------

[a fhir:Claim ;
  fhir:nodeRole fhir:treeRoot ;
  fhir:id [ fhir:v "MED-00050"] ; # 
  fhir:text [
     fhir:status [ fhir:v "generated" ] ;
     fhir:div "<div xmlns=\"http://www.w3.org/1999/xhtml\">A human-readable rendering of a CMS 1500 Claim</div>"
  ] ; # 
  fhir:contained ( [
     a fhir:Patient ;
     fhir:id [ fhir:v "patient-1" ] ;
     fhir:name ( [
       fhir:use [ fhir:v "official" ] ;
       fhir:family [ fhir:v "Ashcraft" ] ;
       fhir:given ( [ fhir:v "Alvina" ] )
     ] ) ;
     fhir:gender [ fhir:v "female" ] ;
     fhir:birthDate [ fhir:v "1954-06-11"^^xsd:date ] ;
     fhir:address ( [
       fhir:use [ fhir:v "home" ] ;
       fhir:line ( [ fhir:v "123 Main Street" ] ) ;
       fhir:city [ fhir:v "Portland" ] ;
       fhir:state [ fhir:v "OR" ] ;
       fhir:postalCode [ fhir:v "97125" ] ;
       fhir:country [ fhir:v "USA" ]
     ] )
  ] [
     a fhir:Coverage ;
     fhir:id [ fhir:v "coverage-1" ] ;
     fhir:identifier ( [
       fhir:system [ fhir:v "http://benefitsinc.com/certificate"^^xsd:anyURI ] ;
       fhir:value [ fhir:v "10138556" ]
     ] ) ;
     fhir:status [ fhir:v "active" ] ;
     fhir:kind [ fhir:v "insurance" ] ;
     fhir:type [
       fhir:coding ( [
         fhir:system [ fhir:v "http://terminology.hl7.org/CodeSystem/v3-ActCode"^^xsd:anyURI ] ;
         fhir:code [ fhir:v "HIP" ] ;
         fhir:display [ fhir:v "health insurance plan policy" ]
       ] )
     ] ;
     fhir:subscriber [
       fhir:reference [ fhir:v "#patient-1" ]
     ] ;
     fhir:beneficiary [
       fhir:reference [ fhir:v "#patient-1" ]
     ] ;
     fhir:relationship [
       fhir:coding ( [
         fhir:code [ fhir:v "self" ]
       ] )
     ] ;
     fhir:period [
       fhir:start [ fhir:v "2015-01-01T00:00:00-07:00"^^xsd:dateTime ] ;
       fhir:end [ fhir:v "2016-01-01T00:00:00-07:00"^^xsd:dateTime ]
     ] ;
     fhir:insurer [
       fhir:identifier [
         fhir:system [ fhir:v "http://www.bindb.com/bin"^^xsd:anyURI ] ;
         fhir:value [ fhir:v "123456" ]
       ] ;
       fhir:display [ fhir:v "Humana Inc." ]
     ] ;
     fhir:class ( [
       fhir:type [
         fhir:coding ( [
           fhir:system [ fhir:v "http://terminology.hl7.org/CodeSystem/coverage-class"^^xsd:anyURI ] ;
           fhir:code [ fhir:v "group" ]
         ] )
       ] ;
       fhir:value [
         fhir:value [ fhir:v "80902206" ]
       ]
     ] )
  ] ) ; # 
  fhir:identifier ( [
     fhir:system [ fhir:v "http://CedarArmsMedicalCenter.com/claim"^^xsd:anyURI ] ;
     fhir:value [ fhir:v "MED-00050" ]
  ] ) ; # 
  fhir:status [ fhir:v "active"] ; # 
  fhir:type [
     fhir:coding ( [
       fhir:system [ fhir:v "http://terminology.hl7.org/CodeSystem/claim-type"^^xsd:anyURI ] ;
       fhir:code [ fhir:v "institutional" ]
     ] )
  ] ; # 
  fhir:subType [
     fhir:coding ( [
       fhir:system [ fhir:v "https://www.cms.gov/codes/billtype"^^xsd:anyURI ] ;
       fhir:code [ fhir:v "831" ] ;
       fhir:display [ fhir:v "Hospital Outpatient Surgery performed in an Ambulatory ​Surgical Center" ]
     ] )
  ] ; # 
  fhir:use [ fhir:v "claim"] ; # 
  fhir:patient [
     fhir:reference [ fhir:v "#patient-1" ]
  ] ; # 
  fhir:created [ fhir:v "2015-10-16T00:00:00-07:00"^^xsd:dateTime] ; # 
  fhir:insurer [
     fhir:identifier [
       fhir:system [ fhir:v "http://www.bindb.com/bin"^^xsd:anyURI ] ;
       fhir:value [ fhir:v "123456" ]
     ] ;
     fhir:display [ fhir:v "Humana Inc." ]
  ] ; # 
  fhir:provider [
     fhir:reference [ fhir:v "Organization/1" ]
  ] ; # 
  fhir:priority [
     fhir:coding ( [
       fhir:code [ fhir:v "normal" ]
     ] )
  ] ; # 
  fhir:payee [
     fhir:type [
       fhir:coding ( [
         fhir:system [ fhir:v "http://terminology.hl7.org/CodeSystem/payeetype"^^xsd:anyURI ] ;
         fhir:code [ fhir:v "provider" ]
       ] )
     ] ;
     fhir:party [
       fhir:reference [ fhir:v "Organization/1" ]
     ]
  ] ; # 
  fhir:careTeam ( [
     fhir:sequence [ fhir:v "1"^^xsd:positiveInteger ] ;
     fhir:provider [
       fhir:reference [ fhir:v "Practitioner/example" ]
     ]
  ] ) ; # 
  fhir:supportingInfo ( [
     fhir:sequence [ fhir:v "1"^^xsd:positiveInteger ] ;
     fhir:category [
       fhir:coding ( [
         fhir:system [ fhir:v "http://terminology.hl7.org/CodeSystem/claiminformationcategory"^^xsd:anyURI ] ;
         fhir:code [ fhir:v "hospitalized" ]
       ] )
     ] ;
     fhir:timing [
       a fhir:Period ;
       fhir:start [ fhir:v "2015-10-01T00:00:00-07:00"^^xsd:dateTime ] ;
       fhir:end [ fhir:v "2015-10-05T00:00:00-07:00"^^xsd:dateTime ]
     ]
  ] [
     fhir:sequence [ fhir:v "2"^^xsd:positiveInteger ] ;
     fhir:category [
       fhir:coding ( [
         fhir:system [ fhir:v "http://terminology.hl7.org/CodeSystem/claiminformationcategory"^^xsd:anyURI ] ;
         fhir:code [ fhir:v "discharge" ]
       ] )
     ] ;
     fhir:code [
       fhir:coding ( [
         fhir:system [ fhir:v "https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/SE0801.pdf"^^xsd:anyURI ] ;
         fhir:code [ fhir:v "01" ] ;
         fhir:display [ fhir:v "Discharge to Home or Self Care" ]
       ] )
     ]
  ] ) ; # 
  fhir:diagnosis ( [
     fhir:sequence [ fhir:v "1"^^xsd:positiveInteger ] ;
     fhir:diagnosis [
       a fhir:CodeableConcept ;
       fhir:coding ( [
         fhir:system [ fhir:v "http://hl7.org/fhir/sid/icd-10-cm"^^xsd:anyURI ] ;
         fhir:code [ fhir:v "M96.1" ] ;
         fhir:display [ fhir:v "Postlaminectomy syndrome, not elsewhere classified" ]
       ] )
     ]
  ] [
     fhir:sequence [ fhir:v "2"^^xsd:positiveInteger ] ;
     fhir:diagnosis [
       a fhir:CodeableConcept ;
       fhir:coding ( [
         fhir:system [ fhir:v "http://hl7.org/fhir/sid/icd-10-cm"^^xsd:anyURI ] ;
         fhir:code [ fhir:v "G89.4" ] ;
         fhir:display [ fhir:v "Chronic pain syndrome" ]
       ] )
     ]
  ] [
     fhir:sequence [ fhir:v "3"^^xsd:positiveInteger ] ;
     fhir:diagnosis [
       a fhir:CodeableConcept ;
       fhir:coding ( [
         fhir:system [ fhir:v "http://hl7.org/fhir/sid/icd-10-cm"^^xsd:anyURI ] ;
         fhir:code [ fhir:v "M53.88" ] ;
         fhir:display [ fhir:v "Other specified dorsopathies, sacral and sacrococcygeal region" ]
       ] )
     ]
  ] [
     fhir:sequence [ fhir:v "4"^^xsd:positiveInteger ] ;
     fhir:diagnosis [
       a fhir:CodeableConcept ;
       fhir:coding ( [
         fhir:system [ fhir:v "http://hl7.org/fhir/sid/icd-10-cm"^^xsd:anyURI ] ;
         fhir:code [ fhir:v "M47.816" ] ;
         fhir:display [ fhir:v "Spondylosis without myelopathy or radiculopathy, lumbar region" ]
       ] )
     ]
  ] ) ; # 
  fhir:insurance ( [
     fhir:sequence [ fhir:v "1"^^xsd:positiveInteger ] ;
     fhir:focal [ fhir:v "true"^^xsd:boolean ] ;
     fhir:identifier [
       fhir:system [ fhir:v "http://CedarArmsMedicalCenter.com/claim"^^xsd:anyURI ] ;
       fhir:value [ fhir:v "MED-00050" ]
     ] ;
     fhir:coverage [
       fhir:reference [ fhir:v "#coverage-1" ]
     ]
  ] ) ; # 
  fhir:item ( [
     fhir:sequence [ fhir:v "1"^^xsd:positiveInteger ] ;
     fhir:careTeamSequence ( [ fhir:v "1"^^xsd:positiveInteger ] ) ;
     fhir:diagnosisSequence ( [ fhir:v "2"^^xsd:positiveInteger ] [ fhir:v "4"^^xsd:positiveInteger ] ) ;
     fhir:informationSequence ( [ fhir:v "1"^^xsd:positiveInteger ] ) ;
     fhir:productOrService [
       fhir:coding ( [
         fhir:system [ fhir:v "http://www.ama-assn.org/go/cpt"^^xsd:anyURI ] ;
         fhir:code [ fhir:v "62264" ] ;
         fhir:display [ fhir:v "Surgical Procedures on the Spine and Spinal Cord" ]
       ] )
     ] ;
     fhir:serviced [ fhir:v "2015-10-13"^^xsd:date ] ;
     fhir:location [
       a fhir:CodeableConcept ;
       fhir:coding ( [
         fhir:system [ fhir:v "https://www.cms.gov/medicare/coding/place-of-service-codes/place_of_service_code_set.html"^^xsd:anyURI ] ;
         fhir:code [ fhir:v "24" ] ;
         fhir:display [ fhir:v "Ambulatory Surgical Center" ]
       ] )
     ] ;
     fhir:unitPrice [
       fhir:value [ fhir:v "12500.00"^^xsd:decimal ] ;
       fhir:currency [ fhir:v "USD" ]
     ] ;
     fhir:net [
       fhir:value [ fhir:v "12500.00"^^xsd:decimal ] ;
       fhir:currency [ fhir:v "USD" ]
     ]
  ] ) ; # 
  fhir:total [
     fhir:value [ fhir:v "12500.00"^^xsd:decimal ] ;
     fhir:currency [ fhir:v "USD" ]
  ]] . # 

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Usage note: every effort has been made to ensure that the examples are correct and useful, but they are not a normative part of the specification.