Release 4
This page is part of the FHIR Specification (v4.0.1: R4 - Mixed Normative and STU) in it's permanent home (it will always be available at this URL). The current version which supercedes this version is 5.0.0. For a full list of available versions, see the Directory of published versions 
. Page versions: R5 R4B R4
| Financial Management Work Group | Maturity Level: N/A | Standards Status: Informative | Compartments: Device, Encounter, Patient, Practitioner, RelatedPerson |
Raw Turtle (+ also see Turtle/RDF Format Specification)
Simple US Medical Surgery Claim
Financial
@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 -------------------------------------------------------------------
<http://hl7.org/fhir/Claim/MED-00050> a fhir:Claim;
fhir:nodeRole fhir:treeRoot;
fhir:Resource.id [ fhir:value "MED-00050"];
fhir:DomainResource.text [
fhir:Narrative.status [ fhir:value "generated" ];
fhir:Narrative.div "<div xmlns=\"http://www.w3.org/1999/xhtml\">A human-readable rendering of a CMS 1500 Claim</div>"
];
fhir:DomainResource.contained [
a fhir:Patient;
fhir:index 0;
fhir:Resource.id [ fhir:value "patient-1" ];
fhir:Patient.name [
fhir:index 0;
fhir:HumanName.use [ fhir:value "official" ];
fhir:HumanName.family [ fhir:value "Ashcraft" ];
fhir:HumanName.given [
fhir:value "Alvina";
fhir:index 0
]
];
fhir:Patient.gender [ fhir:value "female" ];
fhir:Patient.birthDate [ fhir:value "1954-06-11"^^xsd:date ];
fhir:Patient.address [
fhir:index 0;
fhir:Address.use [ fhir:value "home" ];
fhir:Address.line [
fhir:value "123 Main Street";
fhir:index 0
];
fhir:Address.city [ fhir:value "Portland" ];
fhir:Address.state [ fhir:value "OR" ];
fhir:Address.postalCode [ fhir:value "97125" ];
fhir:Address.country [ fhir:value "USA" ]
]
], [
a fhir:Coverage;
fhir:index 1;
fhir:Resource.id [ fhir:value "coverage-1" ];
fhir:Coverage.identifier [
fhir:index 0;
fhir:Identifier.system [ fhir:value "http://benefitsinc.com/certificate" ];
fhir:Identifier.value [ fhir:value "10138556" ]
];
fhir:Coverage.status [ fhir:value "active" ];
fhir:Coverage.type [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/v3-ActCode" ];
fhir:Coding.code [ fhir:value "HIP" ];
fhir:Coding.display [ fhir:value "health insurance plan policy" ]
]
];
fhir:Coverage.subscriber [
fhir:Reference.reference [ fhir:value "#patient-1" ]
];
fhir:Coverage.beneficiary [
fhir:Reference.reference [ fhir:value "#patient-1" ]
];
fhir:Coverage.relationship [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.code [ fhir:value "self" ]
]
];
fhir:Coverage.period [
fhir:Period.start [ fhir:value "2015-01-01T00:00:00-07:00"^^xsd:dateTime ];
fhir:Period.end [ fhir:value "2016-01-01T00:00:00-07:00"^^xsd:dateTime ]
];
fhir:Coverage.payor [
fhir:index 0;
fhir:Reference.identifier [
fhir:Identifier.system [ fhir:value "http://www.bindb.com/bin" ];
fhir:Identifier.value [ fhir:value "123456" ]
];
fhir:Reference.display [ fhir:value "Humana Inc." ]
];
fhir:Coverage.class [
fhir:index 0;
fhir:Coverage.class.type [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/coverage-class" ];
fhir:Coding.code [ fhir:value "group" ]
]
];
fhir:Coverage.class.value [ fhir:value "80902206" ]
]
];
fhir:Claim.identifier [
fhir:index 0;
fhir:Identifier.system [ fhir:value "http://CedarArmsMedicalCenter.com/claim" ];
fhir:Identifier.value [ fhir:value "MED-00050" ]
];
fhir:Claim.status [ fhir:value "active"];
fhir:Claim.type [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/claim-type" ];
fhir:Coding.code [ fhir:value "institutional" ]
]
];
fhir:Claim.subType [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "https://www.cms.gov/codes/billtype" ];
fhir:Coding.code [ fhir:value "831" ];
fhir:Coding.display [ fhir:value "Hospital Outpatient Surgery performed in an Ambulatory Surgical Center" ]
]
];
fhir:Claim.use [ fhir:value "claim"];
fhir:Claim.patient [
fhir:Reference.reference [ fhir:value "#patient-1" ]
];
fhir:Claim.created [ fhir:value "2015-10-16T00:00:00-07:00"^^xsd:dateTime];
fhir:Claim.insurer [
fhir:Reference.identifier [
fhir:Identifier.system [ fhir:value "http://www.bindb.com/bin" ];
fhir:Identifier.value [ fhir:value "123456" ]
];
fhir:Reference.display [ fhir:value "Humana Inc." ]
];
fhir:Claim.provider [
fhir:link <http://hl7.org/fhir/Organization/1>;
fhir:Reference.reference [ fhir:value "Organization/1" ]
];
fhir:Claim.priority [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.code [ fhir:value "normal" ]
]
];
fhir:Claim.payee [
fhir:Claim.payee.type [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/payeetype" ];
fhir:Coding.code [ fhir:value "provider" ]
]
];
fhir:Claim.payee.party [
fhir:link <http://hl7.org/fhir/Organization/1>;
fhir:Reference.reference [ fhir:value "Organization/1" ]
]
];
fhir:Claim.careTeam [
fhir:index 0;
fhir:Claim.careTeam.sequence [ fhir:value "1"^^xsd:positiveInteger ];
fhir:Claim.careTeam.provider [
fhir:link <http://hl7.org/fhir/Practitioner/example>;
fhir:Reference.reference [ fhir:value "Practitioner/example" ]
]
];
fhir:Claim.supportingInfo [
fhir:index 0;
fhir:Claim.supportingInfo.sequence [ fhir:value "1"^^xsd:positiveInteger ];
fhir:Claim.supportingInfo.category [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/claiminformationcategory" ];
fhir:Coding.code [ fhir:value "hospitalized" ]
]
];
fhir:Claim.supportingInfo.timingPeriod [
fhir:Period.start [ fhir:value "2015-10-01T00:00:00-07:00"^^xsd:dateTime ];
fhir:Period.end [ fhir:value "2015-10-05T00:00:00-07:00"^^xsd:dateTime ]
]
], [
fhir:index 1;
fhir:Claim.supportingInfo.sequence [ fhir:value "2"^^xsd:positiveInteger ];
fhir:Claim.supportingInfo.category [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/claiminformationcategory" ];
fhir:Coding.code [ fhir:value "discharge" ]
]
];
fhir:Claim.supportingInfo.code [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/SE0801.pdf" ];
fhir:Coding.code [ fhir:value "01" ];
fhir:Coding.display [ fhir:value "Discharge to Home or Self Care" ]
]
]
];
fhir:Claim.diagnosis [
fhir:index 0;
fhir:Claim.diagnosis.sequence [ fhir:value "1"^^xsd:positiveInteger ];
fhir:Claim.diagnosis.diagnosisCodeableConcept [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://hl7.org/fhir/sid/icd-10" ];
fhir:Coding.code [ fhir:value "M96.1" ];
fhir:Coding.display [ fhir:value "Postlaminectomy syndrome" ]
]
]
], [
fhir:index 1;
fhir:Claim.diagnosis.sequence [ fhir:value "2"^^xsd:positiveInteger ];
fhir:Claim.diagnosis.diagnosisCodeableConcept [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://hl7.org/fhir/sid/icd-10" ];
fhir:Coding.code [ fhir:value "G89.4" ];
fhir:Coding.display [ fhir:value "Chronic pain syndrome" ]
]
]
], [
fhir:index 2;
fhir:Claim.diagnosis.sequence [ fhir:value "3"^^xsd:positiveInteger ];
fhir:Claim.diagnosis.diagnosisCodeableConcept [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://hl7.org/fhir/sid/icd-10" ];
fhir:Coding.code [ fhir:value "M53.88" ];
fhir:Coding.display [ fhir:value "Other specified dorsopathies, sacral and sacrococcygeal region" ]
]
]
], [
fhir:index 3;
fhir:Claim.diagnosis.sequence [ fhir:value "4"^^xsd:positiveInteger ];
fhir:Claim.diagnosis.diagnosisCodeableConcept [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://hl7.org/fhir/sid/icd-10" ];
fhir:Coding.code [ fhir:value "M47.816" ];
fhir:Coding.display [ fhir:value "Spondylosis without myelopathy or radiculopathy, lumbar region" ]
]
]
];
fhir:Claim.insurance [
fhir:index 0;
fhir:Claim.insurance.sequence [ fhir:value "1"^^xsd:positiveInteger ];
fhir:Claim.insurance.focal [ fhir:value "true"^^xsd:boolean ];
fhir:Claim.insurance.identifier [
fhir:Identifier.system [ fhir:value "http://CedarArmsMedicalCenter.com/claim" ];
fhir:Identifier.value [ fhir:value "MED-00050" ]
];
fhir:Claim.insurance.coverage [
fhir:Reference.reference [ fhir:value "#coverage-1" ]
]
];
fhir:Claim.item [
fhir:index 0;
fhir:Claim.item.sequence [ fhir:value "1"^^xsd:positiveInteger ];
fhir:Claim.item.careTeamSequence [
fhir:value "1"^^xsd:positiveInteger;
fhir:index 0
];
fhir:Claim.item.diagnosisSequence [
fhir:value "2"^^xsd:positiveInteger;
fhir:index 0
], [
fhir:value "4"^^xsd:positiveInteger;
fhir:index 1
];
fhir:Claim.item.informationSequence [
fhir:value "1"^^xsd:positiveInteger;
fhir:index 0
];
fhir:Claim.item.productOrService [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://www.ama-assn.org/go/cpt" ];
fhir:Coding.code [ fhir:value "62264" ];
fhir:Coding.display [ fhir:value "Surgical Procedures on the Spine and Spinal Cord" ]
]
];
fhir:Claim.item.servicedDate [ fhir:value "2015-10-13"^^xsd:date ];
fhir:Claim.item.locationCodeableConcept [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "https://www.cms.gov/medicare/coding/place-of-service-codes/place_of_service_code_set.html" ];
fhir:Coding.code [ fhir:value "24" ];
fhir:Coding.display [ fhir:value "Ambulatory Surgical Center" ]
]
];
fhir:Claim.item.unitPrice [
fhir:Money.value [ fhir:value "12500.00"^^xsd:decimal ];
fhir:Money.currency [ fhir:value "USD" ]
];
fhir:Claim.item.net [
fhir:Money.value [ fhir:value "12500.00"^^xsd:decimal ];
fhir:Money.currency [ fhir:value "USD" ]
]
];
fhir:Claim.total [
fhir:Money.value [ fhir:value "12500.00"^^xsd:decimal ];
fhir:Money.currency [ fhir:value "USD" ]
] .
<http://hl7.org/fhir/Organization/1> a fhir:Organization .
<http://hl7.org/fhir/Practitioner/example> a fhir:Practitioner .
# - ontology header ------------------------------------------------------------
<http://hl7.org/fhir/Claim/MED-00050.ttl> a owl:Ontology;
owl:imports fhir:fhir.ttl;
owl:versionIRI <http://build.fhir.org/Claim/MED-00050.ttl> .
# -------------------------------------------------------------------------------------
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.
®© HL7.org 2011+. FHIR Release 4 (Technical Correction #1) (v4.0.1) generated on Fri, Nov 1, 2019 09:34+1100. QA Page
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