Release 5 FHIR CI-Build

This page is part of the Continuous Integration Build of FHIR Specification (v5.0.0: R5 - STU ). This is the current published version in it's permanent home (it will always (will be available incorrect/inconsistent at this URL). For a full list of available versions, see times).
See the Directory of published versions . Page versions: R5 R4B R4 R3

Example Claim/660152 (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 )

Glasses Claim, 3 Tier, Secondary Coverage 

{
  "resourceType" : "Claim",
  "id" : "660152",
  "text" : {
    "status" : "generated",
    "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\">A human-readable rendering of the Vision Claim for Glasses</div>"
  },
  "contained" : [{
    "resourceType" : "Device",
    "id" : "device-frame"
  },
  {
    "resourceType" : "Device",
    "id" : "device-lens"
  }],
  "identifier" : [{
    "system" : "http://happysight.com/claim",
    "value" : "6612347"
  }],
  "status" : "active",
  "type" : {
    "coding" : [{
      "system" : "http://terminology.hl7.org/CodeSystem/claim-type",
      "code" : "vision"
    }]
  },
  "use" : "claim",
  "patient" : {

  "subject" : {

    "reference" : "Patient/1"
  },
  "created" : "2014-08-16",
  "insurer" : {
    "reference" : "Organization/2"
  },
  "provider" : {
    "reference" : "Organization/1"
  },
  "priority" : {
    "coding" : [{
      "code" : "normal"
    }]
  },
  "prescription" : {
    "reference" : "http://www.optdocs.com/prescription/12345"
  },
  "payee" : {
    "type" : {
      "coding" : [{
        "code" : "provider"
      }]
    }
  },
  "careTeam" : [{
    "sequence" : 1,
    "provider" : {
      "reference" : "Practitioner/example"
    }
  }],
  "diagnosis" : [{
    "sequence" : 1,
    "diagnosisCodeableConcept" : {
      "coding" : [{
        "code" : "654321"
      }]
    }
  }],
  "insurance" : [{
    "sequence" : 1,
    "focal" : false,
    "coverage" : {
      "reference" : "Coverage/9876B1"
    },
    "preAuthRef" : ["PR7652387237"],
    "claimResponse" : {
      "reference" : "ClaimResponse/R3500"
    }
  },
  {
    "sequence" : 2,
    "focal" : true,
    "coverage" : {
      "reference" : "Coverage/9876B1"
    },
    "preAuthRef" : ["AB543GTD7567"]
  }],
  "item" : [{
    "sequence" : 1,
    "careTeamSequence" : [1],
    "revenue" : {
      "coding" : [{
        "system" : "http://terminology.hl7.org/CodeSystem/ex-revenue-center",
        "code" : "0010",
        "display" : "Vision Clinic"
      }]
    },
    "category" : {
      "coding" : [{
        "system" : "http://example.org/fhir/CodeSystem/benefit-subcategory",
        "code" : "F6",
        "display" : "Vision Coverage"
      }]
    },
    "productOrService" : {
      "coding" : [{
        "system" : "http://example.org/fhir/CodeSystem/ex-visionservice",
        "code" : "glasses"
      }]
    },
    "modifier" : [{
      "coding" : [{
        "system" : "http://terminology.hl7.org/CodeSystem/modifiers",
        "code" : "rooh"
      }]
    }],
    "programCode" : [{
      "coding" : [{
        "system" : "http://terminology.hl7.org/CodeSystem/ex-programcode",
        "code" : "none"
      }]
    }],
    "servicedDate" : "2014-08-16",
    "unitPrice" : {
      "value" : 235.40,
      "currency" : "USD"
    },
    "net" : {
      "value" : 235.40,
      "currency" : "USD"
    },
    "detail" : [{
      "sequence" : 1,
      "revenue" : {
        "coding" : [{
          "system" : "http://terminology.hl7.org/CodeSystem/ex-revenue-center",
          "code" : "0010",
          "display" : "Vision Clinic"
        }]
      },
      "category" : {
        "coding" : [{
          "system" : "http://example.org/fhir/CodeSystem/benefit-subcategory",
          "code" : "F6",
          "display" : "Vision Coverage"
        }]
      },
      "productOrService" : {
        "coding" : [{
          "system" : "http://example.org/fhir/CodeSystem/ex-visionservice",
          "code" : "frame"
        }]
      },
      "modifier" : [{
        "coding" : [{
          "system" : "http://terminology.hl7.org/CodeSystem/modifiers",
          "code" : "rooh"
        }]
      }],
      "unitPrice" : {
        "value" : 100.00,
        "currency" : "USD"
      },
      "factor" : 1.1,
      "net" : {
        "value" : 110.00,
        "currency" : "USD"
      },
      "udi" : [{
        "reference" : "#device-frame"
      }]
    },
    {
      "sequence" : 2,
      "revenue" : {
        "coding" : [{
          "system" : "http://terminology.hl7.org/CodeSystem/ex-revenue-center",
          "code" : "0010",
          "display" : "Vision Clinic"
        }]
      },
      "category" : {
        "coding" : [{
          "system" : "http://example.org/fhir/CodeSystem/benefit-subcategory",
          "code" : "F6",
          "display" : "Vision Coverage"
        }]
      },
      "productOrService" : {
        "coding" : [{
          "system" : "http://example.org/fhir/CodeSystem/ex-visionservice",
          "code" : "lens"
        }]
      },
      "programCode" : [{
        "coding" : [{
          "system" : "http://terminology.hl7.org/CodeSystem/ex-programcode",
          "code" : "none"
        }]
      }],
      "quantity" : {
        "value" : 2
      },
      "unitPrice" : {
        "value" : 55.00,
        "currency" : "USD"
      },
      "net" : {
        "value" : 110.00,
        "currency" : "USD"
      },
      "subDetail" : [{
        "sequence" : 1,
        "revenue" : {
          "coding" : [{
            "system" : "http://terminology.hl7.org/CodeSystem/ex-revenue-center",
            "code" : "0010",
            "display" : "Vision Clinic"
          }]
        },
        "category" : {
          "coding" : [{
            "system" : "http://example.org/fhir/CodeSystem/benefit-subcategory",
            "code" : "F6",
            "display" : "Vision Coverage"
          }]
        },
        "productOrService" : {
          "coding" : [{
            "system" : "http://example.org/fhir/CodeSystem/ex-visionservice",
            "code" : "lens"
          }]
        },
        "modifier" : [{
          "coding" : [{
            "system" : "http://terminology.hl7.org/CodeSystem/modifiers",
            "code" : "rooh"
          }]
        }],
        "programCode" : [{
          "coding" : [{
            "system" : "http://terminology.hl7.org/CodeSystem/ex-programcode",
            "code" : "none"
          }]
        }],
        "quantity" : {
          "value" : 2
        },
        "unitPrice" : {
          "value" : 30.00,
          "currency" : "USD"
        },
        "factor" : 1.1,
        "net" : {
          "value" : 66.00,
          "currency" : "USD"
        },
        "udi" : [{
          "reference" : "#device-lens"
        }]
      },
      {
        "sequence" : 2,
        "revenue" : {
          "coding" : [{
            "system" : "http://terminology.hl7.org/CodeSystem/ex-revenue-center",
            "code" : "0010",
            "display" : "Vision Clinic"
          }]
        },
        "category" : {
          "coding" : [{
            "system" : "http://example.org/fhir/CodeSystem/benefit-subcategory",
            "code" : "F6",
            "display" : "Vision Coverage"
          }]
        },
        "productOrService" : {
          "coding" : [{
            "system" : "http://example.org/fhir/CodeSystem/ex-visionservice",
            "code" : "hardening"
          }]
        },
        "modifier" : [{
          "coding" : [{
            "system" : "http://terminology.hl7.org/CodeSystem/modifiers",
            "code" : "rooh"
          }]
        }],
        "quantity" : {
          "value" : 2
        },
        "unitPrice" : {
          "value" : 15.00,
          "currency" : "USD"
        },
        "factor" : 1.1,
        "net" : {
          "value" : 33.00,
          "currency" : "USD"
        }
      },
      {
        "sequence" : 3,
        "revenue" : {
          "coding" : [{
            "system" : "http://terminology.hl7.org/CodeSystem/ex-revenue-center",
            "code" : "0010",
            "display" : "Vision Clinic"
          }]
        },
        "category" : {
          "coding" : [{
            "system" : "http://example.org/fhir/CodeSystem/benefit-subcategory",
            "code" : "F6",
            "display" : "Vision Coverage"
          }]
        },
        "productOrService" : {
          "coding" : [{
            "system" : "http://example.org/fhir/CodeSystem/ex-visionservice",
            "code" : "UV coating"
          }]
        },
        "modifier" : [{
          "coding" : [{
            "system" : "http://terminology.hl7.org/CodeSystem/modifiers",
            "code" : "rooh"
          }]
        }],
        "quantity" : {
          "value" : 2
        },
        "unitPrice" : {
          "value" : 5.00,
          "currency" : "USD"
        },
        "factor" : 1.1,
        "net" : {
          "value" : 11.00,
          "currency" : "USD"
        }
      }]
    },
    {
      "sequence" : 3,
      "revenue" : {
        "coding" : [{
          "system" : "http://terminology.hl7.org/CodeSystem/ex-revenue-center",
          "code" : "0010",
          "display" : "Vision Clinic"
        }]
      },
      "category" : {
        "coding" : [{
          "system" : "http://example.org/fhir/CodeSystem/benefit-subcategory",
          "code" : "F6",
          "display" : "Vision Coverage"
        }]
      },
      "productOrService" : {
        "coding" : [{
          "system" : "http://example.org/fhir/CodeSystem/ex-visionservice",
          "code" : "fst"
        }]
      },
      "unitPrice" : {
        "value" : 220.00,
        "currency" : "USD"
      },
      "factor" : 0.07,
      "net" : {
        "value" : 15.40,
        "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.