This page is part of the Quality Improvement Core Framework (v3.1.0: STU 3) based on FHIR R3. The current version which supercedes this version is 4.1.1. For a full list of available versions, see the Directory of published versions 
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{
"resourceType" : "Claim",
"id" : "example",
"meta" : {
"profile" : [
"http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-claim"
]
},
"text" : {
"status" : "generated",
"div" : "<div xmlns="http://www.w3.org/1999/xhtml"><p><b>Generated Narrative with Details</b></p><p><b>id</b>: example</p><p><b>meta</b>: </p><p><b>identifier</b>: 6612346</p><p><b>status</b>: active</p><p><b>type</b>: Vision <span style="background: LightGoldenRodYellow">(Details : {http://hl7.org/fhir/ex-claimtype code 'vision' = 'Vision)</span></p><p><b>use</b>: complete</p><p><b>patient</b>: <a href="Patient-example.html">Generated Summary: id: example; Medical record number = 12345 (USUAL); active; Peter James Chalmers (OFFICIAL), Jim Chalmers , Peter James Windsor (MAIDEN); -unknown-(HOME), ph: (03) 5555 6473(WORK), ph: (03) 3410 5613(MOBILE), ph: (03) 5555 8834(OLD); gender: male; birthDate: 25/12/1974; </a></p><p><b>created</b>: 16/08/2014</p><p><b>insurer</b>: <a href="Organization-example.html">Generated Summary: id: example; ??; active; <span title="Codes: {http://hl7.org/fhir/organization-type team}">Organizational team</span>; name: Health Level Seven International; ph: (+1) 734-677-7777, fax: (+1) 734-677-6622, hq@HL7.org</a></p><p><b>provider</b>: <a href="Practitioner-example.html">Generated Summary: id: example; 23; active; Adam Careful </a></p><p><b>organization</b>: <a href="Organization-example.html">Generated Summary: id: example; ??; active; <span title="Codes: {http://hl7.org/fhir/organization-type team}">Organizational team</span>; name: Health Level Seven International; ph: (+1) 734-677-7777, fax: (+1) 734-677-6622, hq@HL7.org</a></p><p><b>priority</b>: normal <span style="background: LightGoldenRodYellow">(Details : {[not stated] code 'normal' = 'normal)</span></p><p><b>prescription</b>: <a href="MedicationRequest-example.html">Generated Summary: id: example; status: active; intent: order; ????; authoredOn: 25/03/2015 7:32:52 PM; </a></p><h3>Payees</h3><table class="grid"><tr><td>-</td><td><b>Type</b></td><td><b>Party</b></td></tr><tr><td>*</td><td>provider <span style="background: LightGoldenRodYellow">(Details : {[not stated] code 'provider' = 'provider)</span></td><td><a href="Practitioner-example.html">Generated Summary: id: example; 23; active; Adam Careful </a></td></tr></table><h3>CareTeams</h3><table class="grid"><tr><td>-</td><td><b>Sequence</b></td><td><b>Provider</b></td></tr><tr><td>*</td><td>1</td><td><a href="Practitioner-example.html">Generated Summary: id: example; 23; active; Adam Careful </a></td></tr></table><h3>Diagnoses</h3><table class="grid"><tr><td>-</td><td><b>Sequence</b></td><td><b>Diagnosis[x]</b></td></tr><tr><td>*</td><td>1</td><td>654321 <span style="background: LightGoldenRodYellow">(Details : {[not stated] code '654321' = '654321)</span></td></tr></table><h3>Insurances</h3><table class="grid"><tr><td>-</td><td><b>Sequence</b></td><td><b>Focal</b></td><td><b>Coverage</b></td></tr><tr><td>*</td><td>1</td><td>true</td><td><a href="Coverage-example.html">Generated Summary: id: example; 12345; status: active; <span title="Codes: {http://hl7.org/fhir/v3/ActCode EHCPOL}">extended healthcare</span>; <span title="Codes: ">self</span>; period: 23/05/2011 12:00:00 AM --> 23/05/2012 12:00:00 AM; dependent: 0; sequence: 9</a></td></tr></table><blockquote><p><b>item</b></p><p><b>sequence</b>: 1</p><p><b>careTeamLinkId</b>: 1</p><p><b>service</b>: glasses <span style="background: LightGoldenRodYellow">(Details : {http://example.org/fhir/CodeSystem/ex-visionservice code 'glasses' = 'glasses)</span></p><p><b>serviced</b>: 16/08/2014</p><p><b>unitPrice</b>: </p><p><b>net</b>: </p><blockquote><p><b>detail</b></p><p><b>sequence</b>: 1</p><p><b>service</b>: frame <span style="background: LightGoldenRodYellow">(Details : {http://example.org/fhir/CodeSystem/ex-visionservice code 'frame' = 'frame)</span></p><p><b>unitPrice</b>: </p><p><b>net</b>: </p></blockquote><blockquote><p><b>detail</b></p><p><b>sequence</b>: 2</p><p><b>service</b>: lens <span style="background: LightGoldenRodYellow">(Details : {http://example.org/fhir/CodeSystem/ex-visionservice code 'lens' = 'lens)</span></p><p><b>quantity</b>: 2</p><p><b>unitPrice</b>: </p><p><b>net</b>: </p></blockquote><blockquote><p><b>detail</b></p><p><b>sequence</b>: 3</p><p><b>service</b>: fst <span style="background: LightGoldenRodYellow">(Details : {http://example.org/fhir/CodeSystem/ex-visionservice code 'fst' = 'fst)</span></p><p><b>unitPrice</b>: </p><p><b>factor</b>: 0.07</p><p><b>net</b>: </p></blockquote></blockquote></div>"
},
"identifier" : [
{
"system" : "http://happysight.com/claim",
"value" : "6612346"
}
],
"status" : "active",
"type" : {
"coding" : [
{
"system" : "http://hl7.org/fhir/ex-claimtype",
"code" : "vision"
}
]
},
"use" : "complete",
"patient" : {
"reference" : "Patient/example"
},
"created" : "2014-08-16",
"insurer" : {
"reference" : "Organization/example"
},
"provider" : {
"reference" : "Practitioner/example"
},
"organization" : {
"reference" : "Organization/example"
},
"priority" : {
"coding" : [
{
"code" : "normal"
}
]
},
"prescription" : {
"reference" : "MedicationRequest/example"
},
"payee" : {
"type" : {
"coding" : [
{
"code" : "provider"
}
]
},
"party" : {
"reference" : "Practitioner/example"
}
},
"careTeam" : [
{
"sequence" : 1,
"provider" : {
"reference" : "Practitioner/example"
}
}
],
"diagnosis" : [
{
"sequence" : 1,
"diagnosisCodeableConcept" : {
"coding" : [
{
"code" : "654321"
}
]
}
}
],
"insurance" : [
{
"sequence" : 1,
"focal" : true,
"coverage" : {
"reference" : "Coverage/example"
}
}
],
"item" : [
{
"sequence" : 1,
"careTeamLinkId" : [
1
],
"service" : {
"coding" : [
{
"system" : "http://example.org/fhir/CodeSystem/ex-visionservice",
"code" : "glasses"
}
]
},
"servicedDate" : "2014-08-16",
"unitPrice" : {
"value" : 214.00,
"system" : "urn:iso:std:iso:4217",
"code" : "USD"
},
"net" : {
"value" : 214.00,
"system" : "urn:iso:std:iso:4217",
"code" : "USD"
},
"detail" : [
{
"sequence" : 1,
"service" : {
"coding" : [
{
"system" : "http://example.org/fhir/CodeSystem/ex-visionservice",
"code" : "frame"
}
]
},
"unitPrice" : {
"value" : 100.00,
"system" : "urn:iso:std:iso:4217",
"code" : "USD"
},
"net" : {
"value" : 100.00,
"system" : "urn:iso:std:iso:4217",
"code" : "USD"
}
},
{
"sequence" : 2,
"service" : {
"coding" : [
{
"system" : "http://example.org/fhir/CodeSystem/ex-visionservice",
"code" : "lens"
}
]
},
"quantity" : {
"value" : 2
},
"unitPrice" : {
"value" : 50.00,
"system" : "urn:iso:std:iso:4217",
"code" : "USD"
},
"net" : {
"value" : 100.00,
"system" : "urn:iso:std:iso:4217",
"code" : "USD"
}
},
{
"sequence" : 3,
"service" : {
"coding" : [
{
"system" : "http://example.org/fhir/CodeSystem/ex-visionservice",
"code" : "fst"
}
]
},
"unitPrice" : {
"value" : 200.00,
"system" : "urn:iso:std:iso:4217",
"code" : "USD"
},
"factor" : 0.07,
"net" : {
"value" : 14.00,
"system" : "urn:iso:std:iso:4217",
"code" : "USD"
}
}
]
}
]
}
© HL7.org 2011+. QICore STU3 (v3.1.0) (for FHIR v3.0.1-11917) generated on Wed, Aug 22, 2018 23:31+1000. QA Page
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