This page is part of the electronic Long-Term Services and Supports Implementation Guide (v2.0.0: STU2) based on FHIR (HL7® FHIR® Standard) R4. This is the current published version. For a full list of available versions, see the Directory of published versions

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: claim2 - JSON Representation

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{
  "resourceType" : "Claim",
  "id" : "claim2",
  "meta" : {
    "versionId" : "1",
    "lastUpdated" : "2020-09-03T10:16:03.512-04:00",
    "source" : "#KZ0jzPjXDrhCiMif",
    "profile" : [
      🔗 "http://hl7.org/fhir/us/eltss/StructureDefinition/Claim-eltss"
    ]
  },
  "text" : {
    "status" : "generated",
    "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p><b>Generated Narrative: Claim </b><a name=\"claim2\"> </a><a name=\"hcclaim2\"> </a></p><div style=\"display: inline-block; background-color: #d9e0e7; padding: 6px; margin: 4px; border: 1px solid #8da1b4; border-radius: 5px; line-height: 60%\"><p style=\"margin-bottom: 0px\">ResourceClaim &quot;claim2&quot; Version&quot;1&quot; Updated&quot;2020-09-03 10:16:03-0400&quot; </p><p style=\"margin-bottom: 0px\">Information Source: #KZ0jzPjXDrhCiMif!</p><p style=\"margin-bottom: 0px\">Profile: <a href=\"StructureDefinition-Claim-eltss.html\">Claim_eltss</a></p></div><p><b>status</b>: active</p><p><b>type</b>: Professional <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"http://terminology.hl7.org/5.5.0/CodeSystem-claim-type.html\">Claim Type Codes</a>#professional)</span></p><p><b>use</b>: claim</p><p><b>patient</b>: <a href=\"Patient-patientBSJ1.html\">Patient/patientBSJ1</a> &quot; SMITH-JOHNSON&quot;</p><p><b>created</b>: 2020-05-01</p><p><b>provider</b>: <a href=\"Organization-funding1.html\">Organization/funding1</a> &quot;Texas Department of Community Health&quot;</p><p><b>priority</b>: Normal <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"http://terminology.hl7.org/5.5.0/CodeSystem-processpriority.html\">Process Priority Codes</a>#normal)</span></p><h3>Insurances</h3><table class=\"grid\"><tr><td style=\"display: none\">-</td><td><b>Sequence</b></td><td><b>Focal</b></td><td><b>Coverage</b></td></tr><tr><td style=\"display: none\">*</td><td>1</td><td>true</td><td><a href=\"Coverage-coverage1.html\">Coverage/coverage1</a></td></tr></table><blockquote><p><b>item</b></p><p><b>sequence</b>: 1</p><p><b>productOrService</b>: G0108 <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"http://terminology.hl7.org/5.5.0/CodeSystem-hcpcs-Level-II.html\">Healthcare Common Procedure Coding System (HCPCS) level II alphanumeric codes</a>#G0108)</span></p><h3>UnitPrices</h3><table class=\"grid\"><tr><td style=\"display: none\">-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td style=\"display: none\">*</td><td>55</td><td>USD</td></tr></table><h3>Nets</h3><table class=\"grid\"><tr><td style=\"display: none\">-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td style=\"display: none\">*</td><td>660</td><td>USD</td></tr></table></blockquote></div>"
  },
  "status" : "active",
  "type" : {
    "coding" : [
      {
        "system" : "http://terminology.hl7.org/CodeSystem/claim-type",
        "code" : "professional"
      }
    ]
  },
  "use" : "claim",
  "patient" : {
    🔗 "reference" : "Patient/patientBSJ1"
  },
  "created" : "2020-05-01",
  "provider" : {
    🔗 "reference" : "Organization/funding1"
  },
  "priority" : {
    "coding" : [
      {
        "system" : "http://terminology.hl7.org/CodeSystem/processpriority",
        "code" : "normal"
      }
    ]
  },
  "insurance" : [
    {
      "sequence" : 1,
      "focal" : true,
      "coverage" : {
        🔗 "reference" : "Coverage/coverage1"
      }
    }
  ],
  "item" : [
    {
      "sequence" : 1,
      "productOrService" : {
        "coding" : [
          {
            "system" : "http://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets",
            "code" : "G0108"
          }
        ]
      },
      "unitPrice" : {
        "value" : 55,
        "currency" : "USD"
      },
      "net" : {
        "value" : 660,
        "currency" : "USD"
      }
    }
  ]
}