This page is part of the FHIR Specification (v3.2.0: R4 Ballot 1). 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
Claim-example-cms1500-medical.ttl

Financial Management Work Group
Maturity Level: N/A
Ballot Status: Informative
Compartments: Encounter, Patient, Practitioner, RelatedPerson
Raw Turtle, JSON-LD
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 -------------------------------------------------------------------

<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://hl7.org/fhir/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.grouping [
       fhir:Coverage.grouping.group [ 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://hl7.org/fhir/ex-claimtype" ];
       fhir:Coding.code [ fhir:value "institutional" ]
     ]
  ];
  fhir:Claim.subType [
     fhir:index 0;
     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 "complete"];
  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.organization [
     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://hl7.org/fhir/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.information [
     fhir:index 0;
     fhir:Claim.information.sequence [ fhir:value "1"^^xsd:positiveInteger ];
     fhir:Claim.information.category [
       fhir:CodeableConcept.coding [
         fhir:index 0;
         fhir:Coding.system [ fhir:value "http://hl7.org/fhir/claiminformationcategory" ];
         fhir:Coding.code [ fhir:value "discharge" ]
       ]
     ];
     fhir:Claim.information.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.hospitalization [
     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: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.service [
       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:Quantity.value [ fhir:value "12500.00"^^xsd:decimal ];
       fhir:Quantity.system [ fhir:value "urn:iso:std:iso:4217" ];
       fhir:Quantity.code [ fhir:value "USD" ]
     ];
     fhir:Claim.item.net [
       fhir:Quantity.value [ fhir:value "12500.00"^^xsd:decimal ];
       fhir:Quantity.system [ fhir:value "urn:iso:std:iso:4217" ];
       fhir:Quantity.code [ fhir:value "USD" ]
     ]
  ];
  fhir:Claim.total [
     fhir:Quantity.value [ fhir:value "12500.00"^^xsd:decimal ];
     fhir:Quantity.system [ fhir:value "urn:iso:std:iso:4217" ];
     fhir:Quantity.code [ 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.