Release 5 Draft Ballot

This page is part of the FHIR Specification (v4.6.0: R5 Draft Ballot). 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

Claim-example-institutional-rich.json

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

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

Rich Institutional Service Claim

{
  "resourceType": "Claim",
  "id": "960151",
  "text": {
    "status": "generated",
    "div": "<div xmlns=\"http://www.w3.org/1999/xhtml\">A human-readable rendering of the Claim</div>"
  },
  "identifier": [
    {
      "system": "http://happyhospital.com/claim",
      "value": "96123451"
    }
  ],
  "status": "active",
  "type": {
    "coding": [
      {
        "system": "http://terminology.hl7.org/CodeSystem/claim-type",
        "code": "institutional"
      }
    ]
  },
  "use": "claim",
  "patient": {
    "reference": "Patient/1"
  },
  "billablePeriod": {
    "start": "2014-08-15",
    "end": "2014-08-16"
  },
  "created": "2014-08-16",
  "enterer": {
    "identifier": {
      "system": "http://jurisdiction.org/facilities/HOSP1234/users",
      "value": "UC1234"
    }
  },
  "insurer": {
    "reference": "Organization/2"
  },
  "provider": {
    "identifier": {
      "system": "http://npid.org/providerid",
      "value": "NJ12345"
    }
  },
  "priority": {
    "coding": [
      {
        "code": "normal"
      }
    ]
  },
  "payee": {
    "type": {
      "coding": [
        {
          "code": "provider"
        }
      ]
    }
  },
  "facility": {
    "identifier": {
      "system": "http://jurisdiction.org/facilities",
      "value": "HOSP1234"
    }
  },
  "careTeam": [
    {
      "sequence": 1,
      "provider": {
        "reference": "Practitioner/example"
      },
      "responsible": true,
      "role": {
        "coding": [
          {
            "system": "http://example.org/fhir/CodeSystem/claim-careteamrole",
            "code": "primary"
          }
        ]
      },
      "qualification": {
        "coding": [
          {
            "system": "http://example.org/fhir/CodeSystem/provider-qualification",
            "code": "physician"
          }
        ]
      }
    }
  ],
  "supportingInfo": [
    {
      "sequence": 1,
      "category": {
        "coding": [
          {
            "system": "http://terminology.hl7.org/CodeSystem/claiminformationcategory",
            "code": "employmentimpacted"
          }
        ]
      },
      "timingPeriod": {
        "start": "2014-08-16",
        "end": "2014-08-16"
      }
    },
    {
      "sequence": 2,
      "category": {
        "coding": [
          {
            "system": "http://terminology.hl7.org/CodeSystem/claiminformationcategory",
            "code": "hospitalized"
          }
        ]
      },
      "timingPeriod": {
        "start": "2014-08-15",
        "end": "2014-08-16"
      }
    }
  ],
  "diagnosis": [
    {
      "sequence": 1,
      "diagnosisCodeableConcept": {
        "coding": [
          {
            "code": "654456"
          }
        ]
      },
      "type": [
        {
          "coding": [
            {
              "system": "http://terminology.hl7.org/CodeSystem/ex-diagnosistype",
              "code": "admitting"
            }
          ]
        }
      ],
      "packageCode": {
        "coding": [
          {
            "system": "http://terminology.hl7.org/CodeSystem/ex-diagnosisrelatedgroup",
            "code": "400",
            "display": "Head trauma - concussion"
          }
        ]
      }
    }
  ],
  "insurance": [
    {
      "sequence": 1,
      "focal": true,
      "coverage": {
        "reference": "Coverage/9876B1"
      },
      "businessArrangement": "BA987123",
      "preAuthRef": [
        "PA2014G56473"
      ]
    }
  ],
  "accident": {
    "date": "2014-07-09",
    "type": {
      "coding": [
        {
          "system": "http://terminology.hl7.org/CodeSystem/v3-ActIncidentCode",
          "code": "SPT",
          "display": "Sporting Accident"
        }
      ]
    },
    "locationAddress": {
      "text": "Grouse Mountain Ski Hill"
    }
  },
  "item": [
    {
      "sequence": 1,
      "careTeamSequence": [
        1
      ],
      "productOrService": {
        "coding": [
          {
            "system": "http://hl7.org/fhir/ex-serviceproduct",
            "code": "exam"
          }
        ]
      },
      "servicedDate": "2014-08-16",
      "unitPrice": {
        "value": 125.00,
        "currency": "USD"
      },
      "net": {
        "value": 125.00,
        "currency": "USD"
      }
    }
  ],
  "total": {
    "value": 125.00,
    "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.