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>