FHIR Release 3 (STU) 4

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Claim-example-institutional.json

Financial Management Work Group Maturity Level : N/A Ballot Standards Status : Informative Compartments : Device , Encounter , Patient , Practitioner , RelatedPerson

Raw JSON ( canonical form + also see JSON Format Specification )

Simple Institutional Service Claim 

{
  "resourceType": "Claim",
  "id": "960150",
  "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": "9612345"
    }
  ],
  "status": "active",
  "type": {
    "coding": [
      {
        "system": "http://hl7.org/fhir/ex-claimtype",

        "system": "http://terminology.hl7.org/CodeSystem/claim-type",

        "code": "institutional"
      }
    ]
  },
  "subType": [
    {
      "coding": [
        {
          "system": "http://hl7.org/fhir/ex-claimsubtype",
          "code": "emergency"
        }
      ]
    }
  ],
  "use": "complete",

  "subType": {
    "coding": [
      {
        "system": "http://terminology.hl7.org/CodeSystem/ex-claimsubtype",
        "code": "emergency"
      }
    ]
  },
  "use": "claim",

  "patient": {
    "reference": "Patient/1"
  },
  "created": "2014-08-16",
  "enterer": {
    "identifier": {
      "system": "http://jurisdiction.org/facilities/HOSP1234/users",
      "value": "UC1234"
    }
  },
  "insurer": {
    "reference": "Organization/2"
  },
  "organization": {

  "provider": {

    "reference": "Organization/1"
  },
  "priority": {
    "coding": [
      {
        "code": "normal"
      }
    ]
  },
  "payee": {
    "type": {
      "coding": [
        {
          "code": "provider"
        }
      ]
    }
  },
  "facility": {
    "identifier": {
      "system": "http://jurisdiction.org/facilities",
      "value": "HOSP1234"
    }
  },
  "careTeam": [
    {
      "sequence": 1,
      "provider": {
        "reference": "Practitioner/example"
      }
    }
  ],
  "diagnosis": [
    {
      "sequence": 1,
      "diagnosisCodeableConcept": {
        "coding": [
          {
            "code": "654456"
          }
        ]
      }
    }
  ],
  "procedure": [
    {
      "sequence": 1,
      "type": [
        {
          "coding": [
            {
              "code": "primary"
            }
          ]
        }
      ],
      "date": "2014-08-16",
      "procedureCodeableConcept": {
        "coding": [
          {
            "code": "SDI9901"
          }
        ],
        "text": "Subcutaneous diagnostic implant"
      },
      "udi": [
        {
          "reference": "Device/example"
        }
      ]
    }
  ],

  "insurance": [
    {
      "sequence": 1,
      "focal": true,
      "coverage": {
        "reference": "Coverage/9876B1"
      }
    }
  ],
  "item": [
    {
      "sequence": 1,
      "careTeamLinkId": [

      "careTeamSequence": [

        1
      ],
      "service": {

      "productOrService": {

        "coding": [
          {
            "system": "http://hl7.org/fhir/ex-serviceproduct",
            "code": "exam"
          }
        ]
      },
      "servicedDate": "2014-08-16",
      "unitPrice": {
        "value": 125.00,
        "system": "urn:iso:std:iso:4217",
        "code": "USD"

        "currency": "USD"

      },
      "net": {
        "value": 125.00,
        "system": "urn:iso:std:iso:4217",
        "code": "USD"

        "currency": "USD"

      },
      "encounter": [
        {
          "reference": "Encounter/example"
        }
      ]
    }
  ],
  "total": {
    "value": 125.00,
    "system": "urn:iso:std:iso:4217",
    "code": "USD"

    "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.