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| Responsible Owner: Financial Management Work Group | Standards Status : Informative | Compartments : Device , Encounter , Group , Patient , Practitioner , RelatedPerson |
Raw JSON ( canonical form + also see JSON Format Specification )
Simple US Medical Surgery Claim
Financial
{
"resourceType": "Claim",
"id": "MED-00050",
"text": {
"status": "generated",
"div": "<div xmlns=\"http://www.w3.org/1999/xhtml\">A human-readable rendering of a CMS 1500 Claim</div>"
"resourceType" : "Claim",
"id" : "MED-00050",
"text" : {
"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\">A human-readable rendering of a CMS 1500 Claim</div>"
},
"contained": [
{
"resourceType": "Patient",
"id": "patient-1",
"name": [
{
"use": "official",
"family": "Ashcraft",
"given": [
"Alvina"
]
}
],
"gender": "female",
"birthDate": "1954-06-11",
"address": [
{
"use": "home",
"line": [
"123 Main Street"
],
"city": "Portland",
"state": "OR",
"postalCode": "97125",
"country": "USA"
}
]
"contained" : [{
"resourceType" : "Patient",
"id" : "patient-1",
"name" : [{
"use" : "official",
"family" : "Ashcraft",
"given" : ["Alvina"]
}],
"gender" : "female",
"birthDate" : "1954-06-11",
"address" : [{
"use" : "home",
"line" : ["123 Main Street"],
"city" : "Portland",
"state" : "OR",
"postalCode" : "97125",
"country" : "USA"
}]
},
{
"resourceType" : "Coverage",
"id" : "coverage-1",
"identifier" : [{
"system" : "http://benefitsinc.com/certificate",
"value" : "10138556"
}],
"status" : "active",
"kind" : "insurance",
"type" : {
"coding" : [{
"system" : "http://terminology.hl7.org/CodeSystem/v3-ActCode",
"code" : "HIP",
"display" : "health insurance plan policy"
}]
},
{
"resourceType": "Coverage",
"id": "coverage-1",
"identifier": [
{
"system": "http://benefitsinc.com/certificate",
"value": "10138556"
}
],
"status": "active",
"type": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/v3-ActCode",
"code": "HIP",
"display": "health insurance plan policy"
}
]
},
"subscriber": {
"reference": "#patient-1"
},
"beneficiary": {
"reference": "#patient-1"
},
"relationship": {
"coding": [
{
"code": "self"
}
]
"subscriber" : {
"reference" : "#patient-1"
},
"beneficiary" : {
"reference" : "#patient-1"
},
"relationship" : {
"coding" : [{
"code" : "self"
}]
},
"period" : {
"start" : "2015-01-01T00:00:00-07:00",
"end" : "2016-01-01T00:00:00-07:00"
},
"insurer" : {
"identifier" : {
"system" : "http://www.bindb.com/bin",
"value" : "123456"
},
"period": {
"start": "2015-01-01T00:00:00-07:00",
"end": "2016-01-01T00:00:00-07:00"
"display" : "Humana Inc."
},
"class" : [{
"type" : {
"coding" : [{
"system" : "http://terminology.hl7.org/CodeSystem/coverage-class",
"code" : "group"
}]
},
"payor": [
{
"identifier": {
"system": "http://www.bindb.com/bin",
"value": "123456"
},
"display": "Humana Inc."
}
],
"class": [
{
"type": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/coverage-class",
"code": "group"
}
]
},
"value": "80902206"
}
]
}
],
"identifier": [
{
"system": "http://CedarArmsMedicalCenter.com/claim",
"value": "MED-00050"
}
],
"status": "active",
"type": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/claim-type",
"code": "institutional"
"value" : {
"value" : "80902206"
}
]
}]
}],
"identifier" : [{
"system" : "http://CedarArmsMedicalCenter.com/claim",
"value" : "MED-00050"
}],
"status" : "active",
"type" : {
"coding" : [{
"system" : "http://terminology.hl7.org/CodeSystem/claim-type",
"code" : "institutional"
}]
},
"subType": {
"coding": [
{
"system": "https://www.cms.gov/codes/billtype",
"code": "831",
"display": "Hospital Outpatient Surgery performed in an Ambulatory Surgical Center"
}
]
"subType" : {
"coding" : [{
"system" : "https://www.cms.gov/codes/billtype",
"code" : "831",
"display" : "Hospital Outpatient Surgery performed in an Ambulatory Surgical Center"
}]
},
"use": "claim",
"patient": {
"reference": "#patient-1"
"use" : "claim",
"subject" : {
"reference" : "#patient-1"
},
"created": "2015-10-16T00:00:00-07:00",
"insurer": {
"identifier": {
"system": "http://www.bindb.com/bin",
"value": "123456"
"created" : "2015-10-16T00:00:00-07:00",
"insurer" : {
"identifier" : {
"system" : "http://www.bindb.com/bin",
"value" : "123456"
},
"display": "Humana Inc."
"display" : "Humana Inc."
},
"provider": {
"reference": "Organization/1"
"provider" : {
"reference" : "Organization/1"
},
"priority": {
"coding": [
{
"code": "normal"
}
]
"priority" : {
"coding" : [{
"code" : "normal"
}]
},
"payee": {
"type": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/payeetype",
"code": "provider"
}
]
"payee" : {
"type" : {
"coding" : [{
"system" : "http://terminology.hl7.org/CodeSystem/payeetype",
"code" : "provider"
}]
},
"party": {
"reference": "Organization/1"
"party" : {
"reference" : "Organization/1"
}
},
"careTeam": [
{
"sequence": 1,
"provider": {
"reference": "Practitioner/example"
}
"careTeam" : [{
"sequence" : 1,
"provider" : {
"reference" : "Practitioner/example"
}
],
"supportingInfo": [
{
"sequence": 1,
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/claiminformationcategory",
"code": "hospitalized"
}
]
},
"timingPeriod": {
"start": "2015-10-01T00:00:00-07:00",
"end": "2015-10-05T00:00:00-07:00"
}
}],
"supportingInfo" : [{
"sequence" : 1,
"category" : {
"coding" : [{
"system" : "http://terminology.hl7.org/CodeSystem/claiminformationcategory",
"code" : "hospitalized"
}]
},
{
"sequence": 2,
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/claiminformationcategory",
"code": "discharge"
}
]
},
"code": {
"coding": [
{
"system": "https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/SE0801.pdf",
"code": "01",
"display": "Discharge to Home or Self Care"
}
]
}
"timingPeriod" : {
"start" : "2015-10-01T00:00:00-07:00",
"end" : "2015-10-05T00:00:00-07:00"
}
],
"diagnosis": [
{
"sequence": 1,
"diagnosisCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/sid/icd-10",
"code": "M96.1",
"display": "Postlaminectomy syndrome"
}
]
}
},
{
"sequence": 2,
"diagnosisCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/sid/icd-10",
"code": "G89.4",
"display": "Chronic pain syndrome"
}
]
}
},
{
"sequence": 3,
"diagnosisCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/sid/icd-10",
"code": "M53.88",
"display": "Other specified dorsopathies, sacral and sacrococcygeal region"
}
]
}
},
{
"sequence" : 2,
"category" : {
"coding" : [{
"system" : "http://terminology.hl7.org/CodeSystem/claiminformationcategory",
"code" : "discharge"
}]
},
{
"sequence": 4,
"diagnosisCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/sid/icd-10",
"code": "M47.816",
"display": "Spondylosis without myelopathy or radiculopathy, lumbar region"
}
]
}
"code" : {
"coding" : [{
"system" : "https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/SE0801.pdf",
"code" : "01",
"display" : "Discharge to Home or Self Care"
}]
}
],
"insurance": [
{
"sequence": 1,
"focal": true,
"identifier": {
"system": "http://CedarArmsMedicalCenter.com/claim",
"value": "MED-00050"
},
"coverage": {
"reference": "#coverage-1"
}
}],
"diagnosis" : [{
"sequence" : 1,
"diagnosisCodeableConcept" : {
"coding" : [{
"system" : "http://hl7.org/fhir/sid/icd-10-cm",
"code" : "M96.1",
"display" : "Postlaminectomy syndrome, not elsewhere classified"
}]
}
],
"item": [
{
"sequence": 1,
"careTeamSequence": [
1
],
"diagnosisSequence": [
2,
4
],
"informationSequence": [
1
],
"productOrService": {
"coding": [
{
"system": "http://www.ama-assn.org/go/cpt",
"code": "62264",
"display": "Surgical Procedures on the Spine and Spinal Cord"
}
]
},
"servicedDate": "2015-10-13",
"locationCodeableConcept": {
"coding": [
{
"system": "https://www.cms.gov/medicare/coding/place-of-service-codes/place_of_service_code_set.html",
"code": "24",
"display": "Ambulatory Surgical Center"
}
]
},
"unitPrice": {
"value": 12500.00,
"currency": "USD"
},
"net": {
"value": 12500.00,
"currency": "USD"
}
},
{
"sequence" : 2,
"diagnosisCodeableConcept" : {
"coding" : [{
"system" : "http://hl7.org/fhir/sid/icd-10-cm",
"code" : "G89.4",
"display" : "Chronic pain syndrome"
}]
}
],
"total": {
"value": 12500.00,
"currency": "USD"
},
{
"sequence" : 3,
"diagnosisCodeableConcept" : {
"coding" : [{
"system" : "http://hl7.org/fhir/sid/icd-10-cm",
"code" : "M53.88",
"display" : "Other specified dorsopathies, sacral and sacrococcygeal region"
}]
}
},
{
"sequence" : 4,
"diagnosisCodeableConcept" : {
"coding" : [{
"system" : "http://hl7.org/fhir/sid/icd-10-cm",
"code" : "M47.816",
"display" : "Spondylosis without myelopathy or radiculopathy, lumbar region"
}]
}
}],
"insurance" : [{
"sequence" : 1,
"focal" : true,
"identifier" : {
"system" : "http://CedarArmsMedicalCenter.com/claim",
"value" : "MED-00050"
},
"coverage" : {
"reference" : "#coverage-1"
}
}],
"item" : [{
"sequence" : 1,
"careTeamSequence" : [1],
"diagnosisSequence" : [2,
4],
"informationSequence" : [1],
"productOrService" : {
"coding" : [{
"system" : "http://www.ama-assn.org/go/cpt",
"code" : "62264",
"display" : "Percutaneous lysis of epidural adhesions using solution injection (eg, hypertonic saline, enzyme) or mechanical means (eg, catheter) including radiologic localization (includes contrast when administered), multiple adhesiolysis sessions; 1 day"
}]
},
"servicedDate" : "2015-10-13",
"locationCodeableConcept" : {
"coding" : [{
"system" : "https://www.cms.gov/medicare/coding/place-of-service-codes/place_of_service_code_set.html",
"code" : "24",
"display" : "Ambulatory Surgical Center"
}]
},
"unitPrice" : {
"value" : 12500.00,
"currency" : "USD"
},
"net" : {
"value" : 12500.00,
"currency" : "USD"
}
}],
"total" : {
"value" : 12500.00,
"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.
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hl7.fhir.core#6.0.0-ballot3
generated
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09:34+1100.
QA
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