Release 4

Claim-example-cms1500-medical.json

Financial Management Work GroupMaturity Level: N/AStandards Status: InformativeCompartments: Device, Encounter, Patient, Practitioner, RelatedPerson

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

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",
      "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"
      },
      "payor": [
        {
          "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": "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": "Surgical Procedures on the Spine and Spinal Cord"
          }
        ]
      },
      "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"
  }
}

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.