Simple US Medical Surgery Claim

{
  "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"
    }]
  },
  {
    "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"
      }]
    },
    "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"
      },
      "display" : "Humana Inc."
    },
    "class" : [{
      "type" : {
        "coding" : [{
          "system" : "http://terminology.hl7.org/CodeSystem/coverage-class",
          "code" : "group"
        }]
      },
      "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"
    }]
  },
  "use" : "claim",
  "patient" : {
    "reference" : "#patient-1"
  },
  "created" : "2015-10-16T00:00:00-07:00",
  "insurer" : {
    "identifier" : {
      "system" : "http://www.bindb.com/bin",
      "value" : "123456"
    },
    "display" : "Humana Inc."
  },
  "provider" : {
    "reference" : "Organization/1"
  },
  "priority" : {
    "coding" : [{
      "code" : "normal"
    }]
  },
  "payee" : {
    "type" : {
      "coding" : [{
        "system" : "http://terminology.hl7.org/CodeSystem/payeetype",
        "code" : "provider"
      }]
    },
    "party" : {
      "reference" : "Organization/1"
    }
  },
  "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"
    }
  },
  {
    "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"
      }]
    }
  }],
  "diagnosis" : [{
    "sequence" : 1,
    "diagnosisCodeableConcept" : {
      "coding" : [{
        "system" : "http://hl7.org/fhir/sid/icd-10-cm",
        "code" : "M96.1",
        "display" : "Postlaminectomy syndrome, not elsewhere classified"
      }]
    }
  },
  {
    "sequence" : 2,
    "diagnosisCodeableConcept" : {
      "coding" : [{
        "system" : "http://hl7.org/fhir/sid/icd-10-cm",
        "code" : "G89.4",
        "display" : "Chronic pain syndrome"
      }]
    }
  },
  {
    "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"
  }
}