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| Financial Management Work Group | Maturity Level : N/A | Standards Status : Informative | Compartments : Device , Encounter , Patient , Practitioner , RelatedPerson |
Raw Turtle (+ also see Turtle/RDF Format Specification )
Simple US Medical Surgery Claim
@prefix fhir: <http://hl7.org/fhir/> . @prefix owl: <http://www.w3.org/2002/07/owl#> . @prefix rdfs: <http://www.w3.org/2000/01/rdf-schema#> . @prefix xsd: <http://www.w3.org/2001/XMLSchema#> . # - resource -------------------------------------------------------------------<http://hl7.org/fhir/Claim/MED-00050> a fhir:Claim; fhir:nodeRole fhir:treeRoot; fhir:Resource.id [ fhir:value "MED-00050"]; fhir:DomainResource.text [ fhir:Narrative.status [ fhir:value "generated" ]; fhir:Narrative.div "<div xmlns=\"http://www.w3.org/1999/xhtml\">A human-readable rendering of a CMS 1500 Claim</div>" ]; fhir:DomainResource.contained [ a fhir:Patient; fhir:index 0; fhir:Resource.id [ fhir:value "patient-1" ]; fhir:Patient.name [ fhir:index 0; fhir:HumanName.use [ fhir:value "official" ]; fhir:HumanName.family [ fhir:value "Ashcraft" ]; fhir:HumanName.given [ fhir:value "Alvina"; fhir:index 0 ] ]; fhir:Patient.gender [ fhir:value "female" ]; fhir:Patient.birthDate [ fhir:value "1954-06-11"^^xsd:date ]; fhir:Patient.address [ fhir:index 0; fhir:Address.use [ fhir:value "home" ]; fhir:Address.line [ fhir:value "123 Main Street"; fhir:index 0 ]; fhir:Address.city [ fhir:value "Portland" ]; fhir:Address.state [ fhir:value "OR" ]; fhir:Address.postalCode [ fhir:value "97125" ]; fhir:Address.country [ fhir:value "USA" ] ] ], [ a fhir:Coverage; fhir:index 1; fhir:Resource.id [ fhir:value "coverage-1" ]; fhir:Coverage.identifier [ fhir:index 0; fhir:Identifier.system [ fhir:value "http://benefitsinc.com/certificate" ]; fhir:Identifier.value [ fhir:value "10138556" ] ]; fhir:Coverage.status [ fhir:value "active" ]; fhir:Coverage.type [ fhir:CodeableConcept.coding [ fhir:index 0; fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/v3-ActCode" ]; fhir:Coding.code [ fhir:value "HIP" ]; fhir:Coding.display [ fhir:value "health insurance plan policy" ] ] ]; fhir:Coverage.subscriber [ fhir:Reference.reference [ fhir:value "#patient-1" ] ]; fhir:Coverage.beneficiary [ fhir:Reference.reference [ fhir:value "#patient-1" ] ]; fhir:Coverage.relationship [ fhir:CodeableConcept.coding [ fhir:index 0; fhir:Coding.code [ fhir:value "self" ] ] ]; fhir:Coverage.period [ fhir:Period.start [ fhir:value "2015-01-01T00:00:00-07:00"^^xsd:dateTime ]; fhir:Period.end [ fhir:value "2016-01-01T00:00:00-07:00"^^xsd:dateTime ] ]; fhir:Coverage.payor [ fhir:index 0; fhir:Reference.identifier [ fhir:Identifier.system [ fhir:value "http://www.bindb.com/bin" ]; fhir:Identifier.value [ fhir:value "123456" ] ]; fhir:Reference.display [ fhir:value "Humana Inc." ] ]; fhir:Coverage.class [ fhir:index 0; fhir:Coverage.class.type [ fhir:CodeableConcept.coding [ fhir:index 0; fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/coverage-class" ]; fhir:Coding.code [ fhir:value "group" ] ] ]; fhir:Coverage.class.value [ fhir:value "80902206" ] ] ]; fhir:Claim.identifier [ fhir:index 0; fhir:Identifier.system [ fhir:value "http://CedarArmsMedicalCenter.com/claim" ]; fhir:Identifier.value [ fhir:value "MED-00050" ] ]; fhir:Claim.status [ fhir:value "active"]; fhir:Claim.type [ fhir:CodeableConcept.coding [ fhir:index 0; fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/claim-type" ]; fhir:Coding.code [ fhir:value "institutional" ] ] ]; fhir:Claim.subType [ fhir:CodeableConcept.coding [ fhir:index 0; fhir:Coding.system [ fhir:value "https://www.cms.gov/codes/billtype" ]; fhir:Coding.code [ fhir:value "831" ]; fhir:Coding.display [ fhir:value "Hospital Outpatient Surgery performed in an Ambulatory Surgical Center" ] ] ]; fhir:Claim.use [ fhir:value "claim"]; fhir:Claim.patient [ fhir:Reference.reference [ fhir:value "#patient-1" ] ]; fhir:Claim.created [ fhir:value "2015-10-16T00:00:00-07:00"^^xsd:dateTime]; fhir:Claim.insurer [ fhir:Reference.identifier [ fhir:Identifier.system [ fhir:value "http://www.bindb.com/bin" ]; fhir:Identifier.value [ fhir:value "123456" ] ]; fhir:Reference.display [ fhir:value "Humana Inc." ] ]; fhir:Claim.provider [ fhir:link <http://hl7.org/fhir/Organization/1>; fhir:Reference.reference [ fhir:value "Organization/1" ] ]; fhir:Claim.priority [ fhir:CodeableConcept.coding [ fhir:index 0; fhir:Coding.code [ fhir:value "normal" ] ] ]; fhir:Claim.payee [ fhir:Claim.payee.type [ fhir:CodeableConcept.coding [ fhir:index 0; fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/payeetype" ]; fhir:Coding.code [ fhir:value "provider" ][a fhir:Claim ; fhir:nodeRole fhir:treeRoot ; fhir:id [ fhir:v "MED-00050"] ; # fhir:text [ fhir:status [ fhir:v "generated" ] ; fhir:div "<div xmlns=\"http://www.w3.org/1999/xhtml\">A human-readable rendering of a CMS 1500 Claim</div>" ] ; # fhir:contained ( [ a fhir:Patient ; fhir:id [ fhir:v "patient-1" ] ; fhir:name ( [ fhir:use [ fhir:v "official" ] ; fhir:family [ fhir:v "Ashcraft" ] ; fhir:given ( [ fhir:v "Alvina" ] ) ] ) ; fhir:gender [ fhir:v "female" ] ; fhir:birthDate [ fhir:v "1954-06-11"^^xsd:date ] ; fhir:address ( [ fhir:use [ fhir:v "home" ] ; fhir:line ( [ fhir:v "123 Main Street" ] ) ; fhir:city [ fhir:v "Portland" ] ; fhir:state [ fhir:v "OR" ] ; fhir:postalCode [ fhir:v "97125" ] ; fhir:country [ fhir:v "USA" ] ] ) ] [ a fhir:Coverage ; fhir:id [ fhir:v "coverage-1" ] ; fhir:identifier ( [ fhir:system [ fhir:v "http://benefitsinc.com/certificate"^^xsd:anyURI ] ; fhir:value [ fhir:v "10138556" ] ] ) ; fhir:status [ fhir:v "active" ] ; fhir:kind [ fhir:v "insurance" ] ; fhir:type [ fhir:coding ( [ fhir:system [ fhir:v "http://terminology.hl7.org/CodeSystem/v3-ActCode"^^xsd:anyURI ] ; fhir:code [ fhir:v "HIP" ] ; fhir:display [ fhir:v "health insurance plan policy" ] ] ) ] ; fhir:subscriber [ fhir:reference [ fhir:v "#patient-1" ] ] ; fhir:beneficiary [ fhir:reference [ fhir:v "#patient-1" ] ] ; fhir:relationship [ fhir:coding ( [ fhir:code [ fhir:v "self" ] ] ) ] ; fhir:period [ fhir:start [ fhir:v "2015-01-01T00:00:00-07:00"^^xsd:dateTime ] ; fhir:end [ fhir:v "2016-01-01T00:00:00-07:00"^^xsd:dateTime ] ] ; fhir:insurer [ fhir:identifier [ fhir:system [ fhir:v "http://www.bindb.com/bin"^^xsd:anyURI ] ; fhir:value [ fhir:v "123456" ] ] ; fhir:display [ fhir:v "Humana Inc." ] ] ; fhir:class ( [ fhir:type [ fhir:coding ( [ fhir:system [ fhir:v "http://terminology.hl7.org/CodeSystem/coverage-class"^^xsd:anyURI ] ; fhir:code [ fhir:v "group" ] ] ) ] ; fhir:value [ fhir:value [ fhir:v "80902206" ] ]]; fhir:Claim.payee.party [ fhir:link <http://hl7.org/fhir/Organization/1>; fhir:Reference.reference [ fhir:value "Organization/1" ]] ) ] ) ; # fhir:identifier ( [ fhir:system [ fhir:v "http://CedarArmsMedicalCenter.com/claim"^^xsd:anyURI ] ; fhir:value [ fhir:v "MED-00050" ] ] ) ; # fhir:status [ fhir:v "active"] ; # fhir:type [ fhir:coding ( [ fhir:system [ fhir:v "http://terminology.hl7.org/CodeSystem/claim-type"^^xsd:anyURI ] ; fhir:code [ fhir:v "institutional" ] ] ) ] ; # fhir:subType [ fhir:coding ( [ fhir:system [ fhir:v "https://www.cms.gov/codes/billtype"^^xsd:anyURI ] ; fhir:code [ fhir:v "831" ] ; fhir:display [ fhir:v "Hospital Outpatient Surgery performed in an Ambulatory Surgical Center" ] ] ) ] ; # fhir:use [ fhir:v "claim"] ; # fhir:patient [ fhir:reference [ fhir:v "#patient-1" ] ] ; # fhir:created [ fhir:v "2015-10-16T00:00:00-07:00"^^xsd:dateTime] ; # fhir:insurer [ fhir:identifier [ fhir:system [ fhir:v "http://www.bindb.com/bin"^^xsd:anyURI ] ; fhir:value [ fhir:v "123456" ] ] ; fhir:display [ fhir:v "Humana Inc." ] ] ; # fhir:provider [ fhir:reference [ fhir:v "Organization/1" ] ] ; # fhir:priority [ fhir:coding ( [ fhir:code [ fhir:v "normal" ] ] ) ] ; # fhir:payee [ fhir:type [ fhir:coding ( [ fhir:system [ fhir:v "http://terminology.hl7.org/CodeSystem/payeetype"^^xsd:anyURI ] ; fhir:code [ fhir:v "provider" ] ] ) ] ; fhir:party [ fhir:reference [ fhir:v "Organization/1" ] ]]; fhir:Claim.careTeam [ fhir:index 0; fhir:Claim.careTeam.sequence [ fhir:value "1"^^xsd:positiveInteger ]; fhir:Claim.careTeam.provider [ fhir:link <http://hl7.org/fhir/Practitioner/example>; fhir:Reference.reference [ fhir:value "Practitioner/example" ]] ; # fhir:careTeam ( [ fhir:sequence [ fhir:v "1"^^xsd:positiveInteger ] ; fhir:provider [ fhir:reference [ fhir:v "Practitioner/example" ] ]]; fhir:Claim.supportingInfo [ fhir:index 0; fhir:Claim.supportingInfo.sequence [ fhir:value "1"^^xsd:positiveInteger ]; fhir:Claim.supportingInfo.category [ fhir:CodeableConcept.coding [ fhir:index 0; fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/claiminformationcategory" ]; fhir:Coding.code [ fhir:value "hospitalized" ] ] ]; fhir:Claim.supportingInfo.timingPeriod [ fhir:Period.start [ fhir:value "2015-10-01T00:00:00-07:00"^^xsd:dateTime ]; fhir:Period.end [ fhir:value "2015-10-05T00:00:00-07:00"^^xsd:dateTime ]] ) ; # fhir:supportingInfo ( [ fhir:sequence [ fhir:v "1"^^xsd:positiveInteger ] ; fhir:category [ fhir:coding ( [ fhir:system [ fhir:v "http://terminology.hl7.org/CodeSystem/claiminformationcategory"^^xsd:anyURI ] ; fhir:code [ fhir:v "hospitalized" ] ] ) ] ; fhir:timing [ a fhir:Period ; fhir:start [ fhir:v "2015-10-01T00:00:00-07:00"^^xsd:dateTime ] ; fhir:end [ fhir:v "2015-10-05T00:00:00-07:00"^^xsd:dateTime ] ]], [ fhir:index 1; fhir:Claim.supportingInfo.sequence [ fhir:value "2"^^xsd:positiveInteger ]; fhir:Claim.supportingInfo.category [ fhir:CodeableConcept.coding [ fhir:index 0; fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/claiminformationcategory" ]; fhir:Coding.code [ fhir:value "discharge" ] ] ]; fhir:Claim.supportingInfo.code [ fhir:CodeableConcept.coding [ fhir:index 0; fhir:Coding.system [ fhir:value "https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/SE0801.pdf" ]; fhir:Coding.code [ fhir:value "01" ]; fhir:Coding.display [ fhir:value "Discharge to Home or Self Care" ] ]] [ fhir:sequence [ fhir:v "2"^^xsd:positiveInteger ] ; fhir:category [ fhir:coding ( [ fhir:system [ fhir:v "http://terminology.hl7.org/CodeSystem/claiminformationcategory"^^xsd:anyURI ] ; fhir:code [ fhir:v "discharge" ] ] ) ] ; fhir:code [ fhir:coding ( [ fhir:system [ fhir:v "https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/SE0801.pdf"^^xsd:anyURI ] ; fhir:code [ fhir:v "01" ] ; fhir:display [ fhir:v "Discharge to Home or Self Care" ] ] ) ]]; fhir:Claim.diagnosis [ fhir:index 0; fhir:Claim.diagnosis.sequence [ fhir:value "1"^^xsd:positiveInteger ]; fhir:Claim.diagnosis.diagnosisCodeableConcept [ fhir:CodeableConcept.coding [ fhir:index 0; fhir:Coding.system [ fhir:value "http://hl7.org/fhir/sid/icd-10-cm" ]; fhir:Coding.code [ fhir:value "M96.1" ]; fhir:Coding.display [ fhir:value "Postlaminectomy syndrome, not elsewhere classified" ] ]] ) ; # fhir:diagnosis ( [ fhir:sequence [ fhir:v "1"^^xsd:positiveInteger ] ; fhir:diagnosis [ a fhir:CodeableConcept ; fhir:coding ( [ fhir:system [ fhir:v "http://hl7.org/fhir/sid/icd-10-cm"^^xsd:anyURI ] ; fhir:code [ fhir:v "M96.1" ] ; fhir:display [ fhir:v "Postlaminectomy syndrome, not elsewhere classified" ] ] ) ]], [ fhir:index 1; fhir:Claim.diagnosis.sequence [ fhir:value "2"^^xsd:positiveInteger ]; fhir:Claim.diagnosis.diagnosisCodeableConcept [ fhir:CodeableConcept.coding [ fhir:index 0; fhir:Coding.system [ fhir:value "http://hl7.org/fhir/sid/icd-10-cm" ]; fhir:Coding.code [ fhir:value "G89.4" ]; fhir:Coding.display [ fhir:value "Chronic pain syndrome" ] ]] [ fhir:sequence [ fhir:v "2"^^xsd:positiveInteger ] ; fhir:diagnosis [ a fhir:CodeableConcept ; fhir:coding ( [ fhir:system [ fhir:v "http://hl7.org/fhir/sid/icd-10-cm"^^xsd:anyURI ] ; fhir:code [ fhir:v "G89.4" ] ; fhir:display [ fhir:v "Chronic pain syndrome" ] ] ) ]], [ fhir:index 2; fhir:Claim.diagnosis.sequence [ fhir:value "3"^^xsd:positiveInteger ]; fhir:Claim.diagnosis.diagnosisCodeableConcept [ fhir:CodeableConcept.coding [ fhir:index 0; fhir:Coding.system [ fhir:value "http://hl7.org/fhir/sid/icd-10-cm" ]; fhir:Coding.code [ fhir:value "M53.88" ]; fhir:Coding.display [ fhir:value "Other specified dorsopathies, sacral and sacrococcygeal region" ] ]] [ fhir:sequence [ fhir:v "3"^^xsd:positiveInteger ] ; fhir:diagnosis [ a fhir:CodeableConcept ; fhir:coding ( [ fhir:system [ fhir:v "http://hl7.org/fhir/sid/icd-10-cm"^^xsd:anyURI ] ; fhir:code [ fhir:v "M53.88" ] ; fhir:display [ fhir:v "Other specified dorsopathies, sacral and sacrococcygeal region" ] ] ) ]], [ fhir:index 3; fhir:Claim.diagnosis.sequence [ fhir:value "4"^^xsd:positiveInteger ]; fhir:Claim.diagnosis.diagnosisCodeableConcept [ fhir:CodeableConcept.coding [ fhir:index 0; fhir:Coding.system [ fhir:value "http://hl7.org/fhir/sid/icd-10-cm" ]; fhir:Coding.code [ fhir:value "M47.816" ]; fhir:Coding.display [ fhir:value "Spondylosis without myelopathy or radiculopathy, lumbar region" ] ]] [ fhir:sequence [ fhir:v "4"^^xsd:positiveInteger ] ; fhir:diagnosis [ a fhir:CodeableConcept ; fhir:coding ( [ fhir:system [ fhir:v "http://hl7.org/fhir/sid/icd-10-cm"^^xsd:anyURI ] ; fhir:code [ fhir:v "M47.816" ] ; fhir:display [ fhir:v "Spondylosis without myelopathy or radiculopathy, lumbar region" ] ] ) ]]; fhir:Claim.insurance [ fhir:index 0; fhir:Claim.insurance.sequence [ fhir:value "1"^^xsd:positiveInteger ]; fhir:Claim.insurance.focal [ fhir:value "true"^^xsd:boolean ]; fhir:Claim.insurance.identifier [ fhir:Identifier.system [ fhir:value "http://CedarArmsMedicalCenter.com/claim" ]; fhir:Identifier.value [ fhir:value "MED-00050" ] ]; fhir:Claim.insurance.coverage [ fhir:Reference.reference [ fhir:value "#coverage-1" ]] ) ; # fhir:insurance ( [ fhir:sequence [ fhir:v "1"^^xsd:positiveInteger ] ; fhir:focal [ fhir:v "true"^^xsd:boolean ] ; fhir:identifier [ fhir:system [ fhir:v "http://CedarArmsMedicalCenter.com/claim"^^xsd:anyURI ] ; fhir:value [ fhir:v "MED-00050" ] ] ; fhir:coverage [ fhir:reference [ fhir:v "#coverage-1" ] ]]; fhir:Claim.item [ fhir:index 0; fhir:Claim.item.sequence [ fhir:value "1"^^xsd:positiveInteger ]; fhir:Claim.item.careTeamSequence [ fhir:value "1"^^xsd:positiveInteger; fhir:index 0 ]; fhir:Claim.item.diagnosisSequence [ fhir:value "2"^^xsd:positiveInteger; fhir:index 0 ], [ fhir:value "4"^^xsd:positiveInteger; fhir:index 1 ]; fhir:Claim.item.informationSequence [ fhir:value "1"^^xsd:positiveInteger; fhir:index 0 ]; fhir:Claim.item.productOrService [ fhir:CodeableConcept.coding [ fhir:index 0; fhir:Coding.system [ fhir:value "http://www.ama-assn.org/go/cpt" ]; fhir:Coding.code [ fhir:value "62264" ]; fhir:Coding.display [ fhir:value "Surgical Procedures on the Spine and Spinal Cord" ] ] ]; fhir:Claim.item.servicedDate [ fhir:value "2015-10-13"^^xsd:date ]; fhir:Claim.item.locationCodeableConcept [ fhir:CodeableConcept.coding [ fhir:index 0; fhir:Coding.system [ fhir:value "https://www.cms.gov/medicare/coding/place-of-service-codes/place_of_service_code_set.html" ]; fhir:Coding.code [ fhir:value "24" ]; fhir:Coding.display [ fhir:value "Ambulatory Surgical Center" ] ] ]; fhir:Claim.item.unitPrice [ fhir:Money.value [ fhir:value "12500.00"^^xsd:decimal ]; fhir:Money.currency [ fhir:value "USD" ] ]; fhir:Claim.item.net [ fhir:Money.value [ fhir:value "12500.00"^^xsd:decimal ]; fhir:Money.currency [ fhir:value "USD" ]] ) ; # fhir:item ( [ fhir:sequence [ fhir:v "1"^^xsd:positiveInteger ] ; fhir:careTeamSequence ( [ fhir:v "1"^^xsd:positiveInteger ] ) ; fhir:diagnosisSequence ( [ fhir:v "2"^^xsd:positiveInteger ] [ fhir:v "4"^^xsd:positiveInteger ] ) ; fhir:informationSequence ( [ fhir:v "1"^^xsd:positiveInteger ] ) ; fhir:productOrService [ fhir:coding ( [ fhir:system [ fhir:v "http://www.ama-assn.org/go/cpt"^^xsd:anyURI ] ; fhir:code [ fhir:v "62264" ] ; fhir:display [ fhir:v "Surgical Procedures on the Spine and Spinal Cord" ] ] ) ] ; fhir:serviced [ fhir:v "2015-10-13"^^xsd:date ] ; fhir:location [ a fhir:CodeableConcept ; fhir:coding ( [ fhir:system [ fhir:v "https://www.cms.gov/medicare/coding/place-of-service-codes/place_of_service_code_set.html"^^xsd:anyURI ] ; fhir:code [ fhir:v "24" ] ; fhir:display [ fhir:v "Ambulatory Surgical Center" ] ] ) ] ; fhir:unitPrice [ fhir:value [ fhir:v "12500.00"^^xsd:decimal ] ; fhir:currency [ fhir:v "USD" ] ] ; fhir:net [ fhir:value [ fhir:v "12500.00"^^xsd:decimal ] ; fhir:currency [ fhir:v "USD" ] ]]; fhir:Claim.total [ fhir:Money.value [ fhir:value "12500.00"^^xsd:decimal ]; fhir:Money.currency [ fhir:value "USD" ] ] . <http://hl7.org/fhir/Organization/1> a fhir:Organization . <http://hl7.org/fhir/Practitioner/example> a fhir:Practitioner . # - ontology header ------------------------------------------------------------ <http://hl7.org/fhir/Claim/MED-00050.ttl> a owl:Ontology; owl:imports fhir:fhir.ttl; owl:versionIRI <http://build.fhir.org/Claim/MED-00050.ttl> .] ) ; # fhir:total [ fhir:value [ fhir:v "12500.00"^^xsd:decimal ] ; fhir:currency [ fhir:v "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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FHIR
Release
4B
(v4.3.0)
hl7.fhir.r4b.core#4.3.0
R5
hl7.fhir.core#5.0.0-draft-final
generated
on
Sat,
May
28,
2022
12:54+1000.
Wed,
Mar
1,
2023
23:06+1100.
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