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Claim-example-institutional-rich.json

Example Claim/960151 (JSON)

Maturity Level : N/A
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 )

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>"

  "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"
      }
    ]

  "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"

  "use" : "claim",
  "subject" : {
    "reference" : "Patient/1"

  },
  "billablePeriod": {
    "start": "2014-08-15",
    "end": "2014-08-16"

  "billablePeriod" : {
    "start" : "2014-08-15",
    "end" : "2014-08-16"

  },
  "created": "2014-08-16",
  "enterer": {
    "identifier": {
      "system": "http://jurisdiction.org/facilities/HOSP1234/users",
      "value": "UC1234"

  "created" : "2014-08-16",
  "enterer" : {
    "identifier" : {
      "system" : "http://jurisdiction.org/facilities/HOSP1234/users",
      "value" : "UC1234"

    }
  },
  "insurer": {
    "reference": "Organization/2"

  "insurer" : {
    "reference" : "Organization/2"

  },
  "provider": {
    "identifier": {
      "system": "http://npid.org/providerid",
      "value": "NJ12345"

  "provider" : {
    "identifier" : {
      "system" : "http://npid.org/providerid",
      "value" : "NJ12345"

    }
  },
  "priority": {
    "coding": [
      {
        "code": "normal"
      }
    ]

  "priority" : {
    "coding" : [{
      "code" : "normal"
    }]

  },
  "payee": {
    "type": {
      "coding": [
        {
          "code": "provider"
        }
      ]

  "payee" : {
    "type" : {
      "coding" : [{
        "code" : "provider"
      }]

    }
  },
  "facility": {
    "identifier": {
      "system": "http://jurisdiction.org/facilities",
      "value": "HOSP1234"

  "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"
      }

  "diagnosisRelatedGroup" : {
    "coding" : [{
      "system" : "http://terminology.hl7.org/CodeSystem/ex-diagnosisrelatedgroup",
      "code" : "400",
      "display" : "Head trauma - concussion"
    }]
  },
  "careTeam" : [{
    "sequence" : 1,
    "provider" : {
      "reference" : "Practitioner/example"

    },
    {
      "sequence": 2,
      "category": {
        "coding": [
          {
            "system": "http://terminology.hl7.org/CodeSystem/claiminformationcategory",
            "code": "hospitalized"
          }
        ]
      },
      "timingPeriod": {
        "start": "2014-08-15",
        "end": "2014-08-16"
      }

    "role" : {
      "coding" : [{
        "system" : "http://example.org/fhir/CodeSystem/claim-careteamrole",
        "code" : "primary"
      }]
    },
    "specialty" : {
      "coding" : [{
        "system" : "http://example.org/fhir/CodeSystem/provider-qualification",
        "code" : "physician"
      }]

    }
  ],
  "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"
          }
        ]
      }

  }],
  "supportingInfo" : [{
    "sequence" : 1,
    "category" : {
      "coding" : [{
        "system" : "http://terminology.hl7.org/CodeSystem/claiminformationcategory",
        "code" : "employmentimpacted"
      }]
    },
    "timingPeriod" : {
      "start" : "2014-08-16",
      "end" : "2014-08-16"

    }
  ],
  "insurance": [
    {
      "sequence": 1,
      "focal": true,
      "coverage": {
        "reference": "Coverage/9876B1"
      },
      "businessArrangement": "BA987123",
      "preAuthRef": [
        "PA2014G56473"
      ]

  },
  {
    "sequence" : 2,
    "category" : {
      "coding" : [{
        "system" : "http://terminology.hl7.org/CodeSystem/claiminformationcategory",
        "code" : "hospitalized"
      }]
    },
    "timingPeriod" : {
      "start" : "2014-08-15",
      "end" : "2014-08-16"

    }
  ],
  "accident": {
    "date": "2014-07-09",
    "type": {
      "coding": [
        {
          "system": "http://terminology.hl7.org/CodeSystem/v3-ActIncidentCode",
          "code": "SPT",
          "display": "Sporting Accident"
        }
      ]

  }],
  "diagnosis" : [{
    "sequence" : 1,
    "diagnosisCodeableConcept" : {
      "coding" : [{
        "code" : "654456"
      }]

    },
    "locationAddress": {
      "text": "Grouse Mountain Ski Hill"

    "type" : [{
      "coding" : [{
        "system" : "http://terminology.hl7.org/CodeSystem/ex-diagnosistype",
        "code" : "admitting"
      }]
    }]
  }],
  "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"
      }

  "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"

  }],
  "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.