This is the Continuous Integration Build of FHIR (will be incorrect/inconsistent at times).
See the Directory of published versions
Financial Management Work Group | Maturity Level: N/A | Standards Status: Informative | Compartments: Device, Encounter, Patient, Practitioner, RelatedPerson |
Raw XML (canonical form + also see XML Format Specification)
Simple US Medical Surgery Claim (id = "MED-00050")
<?xml version="1.0" encoding="UTF-8"?> <Claim xmlns="http://hl7.org/fhir"> <id value="MED-00050"/> <text> <status value="generated"/> <div xmlns="http://www.w3.org/1999/xhtml">A human-readable rendering of a CMS 1500 Claim</div> </text> <contained> <Patient> <id value="patient-1"/> <name> <use value="official"/> <family value="Ashcraft"/> <given value="Alvina"/> </name> <gender value="female"/> <birthDate value="1954-06-11"/> <address> <use value="home"/> <line value="123 Main Street"/> <city value="Portland"/> <state value="OR"/> <postalCode value="97125"/> <country value="USA"/> </address> </Patient> </contained> <contained> <Coverage> <id value="coverage-1"/> <identifier> <system value="http://benefitsinc.com/certificate"/> <value value="10138556"/> </identifier> <status value="active"/> <kind value="insurance"/> <type> <coding> <system value="http://terminology.hl7.org/CodeSystem/v3-ActCode"/> <code value="HIP"/> <display value="health insurance plan policy"/> </coding> </type> <subscriber> <reference value="#patient-1"/> </subscriber> <beneficiary> <reference value="#patient-1"/> </beneficiary> <relationship> <coding> <code value="self"/> </coding> </relationship> <period> <start value="2015-01-01T00:00:00-07:00"/> <end value="2016-01-01T00:00:00-07:00"/> </period> <insurer> <identifier> <system value="http://www.bindb.com/bin"/> <value value="123456"/> </identifier> <display value="Humana Inc."/> </insurer> <class> <type> <coding> <system value="http://terminology.hl7.org/CodeSystem/coverage-class"/> <code value="group"/> </coding> </type> <value> <value value="80902206"/> </value> </class> </Coverage> </contained> <identifier> <system value="http://CedarArmsMedicalCenter.com/claim"/> <value value="MED-00050"/> </identifier> <status value="active"/> <type> <coding> <system value="http://terminology.hl7.org/CodeSystem/claim-type"/> <code value="institutional"/> </coding> </type> <subType> <coding> <system value="https://www.cms.gov/codes/billtype"/> <code value="831"/> <display value="Hospital Outpatient Surgery performed in an Ambulatory Surgical Center"/> </coding> </subType> <use value="claim"/> <patient> <reference value="#patient-1"/> </patient> <created value="2015-10-16T00:00:00-07:00"/> <insurer> <identifier> <system value="http://www.bindb.com/bin"/> <value value="123456"/> </identifier> <display value="Humana Inc."/> </insurer> <provider> <reference value="Organization/1"/> </provider> <priority> <coding> <code value="normal"/> </coding> </priority> <payee> <type> <coding> <system value="http://terminology.hl7.org/CodeSystem/payeetype"/> <code value="provider"/> </coding> </type> <party> <reference value="Organization/1"/> </party> </payee> <careTeam> <sequence value="1"/> <provider> <reference value="Practitioner/example"/> </provider> </careTeam> <supportingInfo> <sequence value="1"/> <category> <coding> <system value="http://terminology.hl7.org/CodeSystem/claiminformationcategory"/> <code value="hospitalized"/> </coding> </category> <timingPeriod> <start value="2015-10-01T00:00:00-07:00"/> <end value="2015-10-05T00:00:00-07:00"/> </timingPeriod> </supportingInfo> <supportingInfo> <sequence value="2"/> <category> <coding> <system value="http://terminology.hl7.org/CodeSystem/claiminformationcategory"/> <code value="discharge"/> </coding> </category> <code> <coding> <system value="https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/d ownloads/SE0801.pdf"/> <code value="01"/> <display value="Discharge to Home or Self Care"/> </coding> </code> </supportingInfo> <diagnosis> <sequence value="1"/> <diagnosisCodeableConcept> <coding> <system value="http://hl7.org/fhir/sid/icd-10-cm"/> <code value="M96.1"/> <display value="Postlaminectomy syndrome, not elsewhere classified"/> </coding> </diagnosisCodeableConcept> </diagnosis> <diagnosis> <sequence value="2"/> <diagnosisCodeableConcept> <coding> <system value="http://hl7.org/fhir/sid/icd-10-cm"/> <code value="G89.4"/> <display value="Chronic pain syndrome"/> </coding> </diagnosisCodeableConcept> </diagnosis> <diagnosis> <sequence value="3"/> <diagnosisCodeableConcept> <coding> <system value="http://hl7.org/fhir/sid/icd-10-cm"/> <code value="M53.88"/> <display value="Other specified dorsopathies, sacral and sacrococcygeal region"/> </coding> </diagnosisCodeableConcept> </diagnosis> <diagnosis> <sequence value="4"/> <diagnosisCodeableConcept> <coding> <system value="http://hl7.org/fhir/sid/icd-10-cm"/> <code value="M47.816"/> <display value="Spondylosis without myelopathy or radiculopathy, lumbar region"/> </coding> </diagnosisCodeableConcept> </diagnosis> <insurance> <sequence value="1"/> <focal value="true"/> <identifier> <system value="http://CedarArmsMedicalCenter.com/claim"/> <value value="MED-00050"/> </identifier> <coverage> <reference value="#coverage-1"/> </coverage> </insurance> <item> <sequence value="1"/> <careTeamSequence value="1"/> <diagnosisSequence value="2"/> <diagnosisSequence value="4"/> <informationSequence value="1"/> <productOrService> <coding> <system value="http://www.ama-assn.org/go/cpt"/> <code value="62264"/> <display value="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"/> </coding> </productOrService> <servicedDate value="2015-10-13"/> <locationCodeableConcept> <coding> <system value="https://www.cms.gov/medicare/coding/place-of-service-codes/place_of_service_code_set.html"/> <code value="24"/> <display value="Ambulatory Surgical Center"/> </coding> </locationCodeableConcept> <unitPrice> <value value="12500.00"/> <currency value="USD"/> </unitPrice> <net> <value value="12500.00"/> <currency value="USD"/> </net> </item> <total> <value value="12500.00"/> <currency value="USD"/> </total> </Claim>
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.
FHIR ®© HL7.org 2011+. FHIR R6 hl7.fhir.core#6.0.0-ballot2 generated on Wed, Oct 2, 2024 17:57+0000.
Links: Search |
Version History |
Contents |
Glossary |
QA |
Compare to R5 |
|
Propose a change