Release 5 Preview #1

This page is part of the FHIR Specification (v4.2.0: R5 Preview #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 R3 R2

Claim-example.json

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

Raw JSON (canonical form + also see JSON Format Specification)

Simple dental Claim

{
  "resourceType": "Claim",
  "id": "100150",
  "text": {
    "status": "generated",
    "div": "<div xmlns=\"http://www.w3.org/1999/xhtml\">A human-readable rendering of the Oral Health Claim</div>"
  },
  "identifier": [
    {
      "system": "http://happyvalley.com/claim",
      "value": "12345"
    }
  ],
  "status": "active",
  "type": {
    "coding": [
      {
        "system": "http://terminology.hl7.org/CodeSystem/claim-type",
        "code": "oral"
      }
    ]
  },
  "use": "claim",
  "patient": {
    "reference": "Patient/1"
  },
  "created": "2014-08-16",
  "insurer": {
    "reference": "Organization/2"
  },
  "provider": {
    "reference": "Organization/1"
  },
  "priority": {
    "coding": [
      {
        "code": "normal"
      }
    ]
  },
  "payee": {
    "type": {
      "coding": [
        {
          "code": "provider"
        }
      ]
    }
  },
  "careTeam": [
    {
      "sequence": 1,
      "provider": {
        "reference": "Practitioner/example"
      }
    }
  ],
  "diagnosis": [
    {
      "sequence": 1,
      "diagnosisCodeableConcept": {
        "coding": [
          {
            "code": "123456"
          }
        ]
      }
    }
  ],
  "insurance": [
    {
      "sequence": 1,
      "focal": true,
      "identifier": {
        "system": "http://happyvalley.com/claim",
        "value": "12345"
      },
      "coverage": {
        "reference": "Coverage/9876B1"
      }
    }
  ],
  "item": [
    {
      "sequence": 1,
      "careTeamSequence": [
        1
      ],
      "productOrService": {
        "coding": [
          {
            "code": "1200"
          }
        ]
      },
      "servicedDate": "2014-08-16",
      "unitPrice": {
        "value": 135.57,
        "currency": "USD"
      },
      "net": {
        "value": 135.57,
        "currency": "USD"
      }
    }
  ]
}

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.