QI-Core Implementation Guide
7.0.0 - STU7 United States of America flag

QI-Core Implementation Guide, published by HL7 International / Clinical Quality Information. This guide is not an authorized publication; it is the continuous build for version 7.0.0 built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/HL7/fhir-qi-core/ and changes regularly. See the Directory of published versions

: Claim example - JSON Representation

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{
  "resourceType" : "Claim",
  "id" : "example",
  "meta" : {
    "profile" : [
      🔗 "http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-claim"
    ]
  },
  "text" : {
    "status" : "generated",
    "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p class=\"res-header-id\"><b>Generated Narrative: Claim example</b></p><a name=\"example\"> </a><a name=\"hcexample\"> </a><a name=\"example-en-US\"> </a><p><b>identifier</b>: <code>http://happysight.com/claim</code>/6612346</p><p><b>status</b>: Active</p><p><b>type</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/claim-type vision}\">Vision</span></p><p><b>use</b>: Claim</p><p><b>patient</b>: <a href=\"Patient-example.html\">Jim Chalmers  Male, DoB: 1974-12-25 ( Medical record number\u00a0(use:\u00a0usual,\u00a0period:\u00a02001-05-06 --&gt; (ongoing)))</a></p><p><b>created</b>: 2014-08-16</p><p><b>insurer</b>: <a href=\"Organization-example.html\">Organization Health Level Seven International</a></p><p><b>provider</b>: <a href=\"Practitioner-example.html\">Practitioner Adam Careful </a></p><p><b>priority</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/processpriority normal}\">Normal</span></p><p><b>prescription</b>: <a href=\"MedicationRequest-example.html\">MedicationRequest: status = active; intent = order; medication[x] = -&gt;Medication alemtuzumab 10 MG/ML [Lemtrada]; authoredOn = 2015-03-25 19:32:52-0500</a></p><h3>Payees</h3><table class=\"grid\"><tr><td style=\"display: none\">-</td><td><b>Type</b></td><td><b>Party</b></td></tr><tr><td style=\"display: none\">*</td><td><span title=\"Codes:{http://terminology.hl7.org/CodeSystem/payeetype provider}\">Provider</span></td><td><a href=\"Practitioner-example.html\">Practitioner Adam Careful </a></td></tr></table><h3>CareTeams</h3><table class=\"grid\"><tr><td style=\"display: none\">-</td><td><b>Sequence</b></td><td><b>Provider</b></td></tr><tr><td style=\"display: none\">*</td><td>1</td><td><a href=\"Practitioner-example.html\">Practitioner Adam Careful </a></td></tr></table><h3>Diagnoses</h3><table class=\"grid\"><tr><td style=\"display: none\">-</td><td><b>Sequence</b></td><td><b>Diagnosis[x]</b></td></tr><tr><td style=\"display: none\">*</td><td>1</td><td><span title=\"Codes:{http://terminology.hl7.org/CodeSystem/icd-10-cm H44.23}\">H44.23</span></td></tr></table><h3>Insurances</h3><table class=\"grid\"><tr><td style=\"display: none\">-</td><td><b>Sequence</b></td><td><b>Focal</b></td><td><b>Coverage</b></td></tr><tr><td style=\"display: none\">*</td><td>1</td><td>true</td><td><a href=\"Coverage-example.html\">Coverage: identifier = Member Number; status = active; type = Other Private Insurance; dependent = 0; relationship = Self; period = 2011-05-23 --&gt; 2012-05-23; order = 9</a></td></tr></table><blockquote><p><b>item</b></p><p><b>sequence</b>: 1</p><p><b>careTeamSequence</b>: 1</p><p><b>productOrService</b>: <span title=\"Codes:{http://example.org/fhir/CodeSystem/ex-visionservice glasses}\">glasses</span></p><p><b>serviced</b>: 2014-08-16</p><h3>UnitPrices</h3><table class=\"grid\"><tr><td style=\"display: none\">-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td style=\"display: none\">*</td><td>214.00</td><td>United States dollar</td></tr></table><blockquote><p><b>detail</b></p><p><b>sequence</b>: 1</p><p><b>productOrService</b>: <span title=\"Codes:{http://example.org/fhir/CodeSystem/ex-visionservice frame}\">frame</span></p><h3>UnitPrices</h3><table class=\"grid\"><tr><td style=\"display: none\">-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td style=\"display: none\">*</td><td>100.00</td><td>United States dollar</td></tr></table><h3>Nets</h3><table class=\"grid\"><tr><td style=\"display: none\">-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td style=\"display: none\">*</td><td>100.00</td><td>United States dollar</td></tr></table></blockquote><blockquote><p><b>detail</b></p><p><b>sequence</b>: 2</p><p><b>productOrService</b>: <span title=\"Codes:{http://example.org/fhir/CodeSystem/ex-visionservice lens}\">lens</span></p><p><b>quantity</b>: 2</p><h3>UnitPrices</h3><table class=\"grid\"><tr><td style=\"display: none\">-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td style=\"display: none\">*</td><td>50.00</td><td>United States dollar</td></tr></table><h3>Nets</h3><table class=\"grid\"><tr><td style=\"display: none\">-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td style=\"display: none\">*</td><td>100.00</td><td>United States dollar</td></tr></table></blockquote><blockquote><p><b>detail</b></p><p><b>sequence</b>: 3</p><p><b>productOrService</b>: <span title=\"Codes:{http://example.org/fhir/CodeSystem/ex-visionservice fst}\">fst</span></p><h3>UnitPrices</h3><table class=\"grid\"><tr><td style=\"display: none\">-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td style=\"display: none\">*</td><td>200.00</td><td>United States dollar</td></tr></table><p><b>factor</b>: 0.07</p><h3>Nets</h3><table class=\"grid\"><tr><td style=\"display: none\">-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td style=\"display: none\">*</td><td>14.00</td><td>United States dollar</td></tr></table></blockquote></blockquote></div>"
  },
  "identifier" : [
    {
      "system" : "http://happysight.com/claim",
      "value" : "6612346"
    }
  ],
  "status" : "active",
  "type" : {
    "coding" : [
      {
        "system" : "http://terminology.hl7.org/CodeSystem/claim-type",
        "code" : "vision"
      }
    ]
  },
  "use" : "claim",
  "patient" : {
    🔗 "reference" : "Patient/example"
  },
  "created" : "2014-08-16",
  "insurer" : {
    🔗 "reference" : "Organization/example"
  },
  "provider" : {
    🔗 "reference" : "Practitioner/example"
  },
  "priority" : {
    "coding" : [
      {
        "system" : "http://terminology.hl7.org/CodeSystem/processpriority",
        "code" : "normal"
      }
    ]
  },
  "prescription" : {
    🔗 "reference" : "MedicationRequest/example"
  },
  "payee" : {
    "type" : {
      "coding" : [
        {
          "system" : "http://terminology.hl7.org/CodeSystem/payeetype",
          "code" : "provider"
        }
      ]
    },
    "party" : {
      🔗 "reference" : "Practitioner/example"
    }
  },
  "careTeam" : [
    {
      "sequence" : 1,
      "provider" : {
        🔗 "reference" : "Practitioner/example"
      }
    }
  ],
  "diagnosis" : [
    {
      "sequence" : 1,
      "diagnosisCodeableConcept" : {
        "coding" : [
          {
            "system" : "http://terminology.hl7.org/CodeSystem/icd-10-cm",
            "code" : "H44.23"
          }
        ]
      }
    }
  ],
  "insurance" : [
    {
      "sequence" : 1,
      "focal" : true,
      "coverage" : {
        🔗 "reference" : "Coverage/example"
      }
    }
  ],
  "item" : [
    {
      "sequence" : 1,
      "careTeamSequence" : [
        1
      ],
      "productOrService" : {
        "coding" : [
          {
            "system" : "http://example.org/fhir/CodeSystem/ex-visionservice",
            "code" : "glasses"
          }
        ]
      },
      "servicedDate" : "2014-08-16",
      "unitPrice" : {
        "value" : 214.00,
        "currency" : "USD"
      },
      "detail" : [
        {
          "sequence" : 1,
          "productOrService" : {
            "coding" : [
              {
                "system" : "http://example.org/fhir/CodeSystem/ex-visionservice",
                "code" : "frame"
              }
            ]
          },
          "unitPrice" : {
            "value" : 100.00,
            "currency" : "USD"
          },
          "net" : {
            "value" : 100.00,
            "currency" : "USD"
          }
        },
        {
          "sequence" : 2,
          "productOrService" : {
            "coding" : [
              {
                "system" : "http://example.org/fhir/CodeSystem/ex-visionservice",
                "code" : "lens"
              }
            ]
          },
          "quantity" : {
            "value" : 2
          },
          "unitPrice" : {
            "value" : 50.00,
            "currency" : "USD"
          },
          "net" : {
            "value" : 100.00,
            "currency" : "USD"
          }
        },
        {
          "sequence" : 3,
          "productOrService" : {
            "coding" : [
              {
                "system" : "http://example.org/fhir/CodeSystem/ex-visionservice",
                "code" : "fst"
              }
            ]
          },
          "unitPrice" : {
            "value" : 200.00,
            "currency" : "USD"
          },
          "factor" : 0.07,
          "net" : {
            "value" : 14.00,
            "currency" : "USD"
          }
        }
      ]
    }
  ]
}