NHDR Implementation Guide Release 1.0
0.1.0 - ci-build

NHDR Implementation Guide Release 1.0, published by NHDR. This guide is not an authorized publication; it is the continuous build for version 0.1.0 built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/PROJ-PHILHEALTH-EA-NHDR/nhdr-fhir-ig-review-project-2/ and changes regularly. See the Directory of published versions

## Claims Form 4

This is a sample representation of the Use Case implementation guide for Claims Form 4

### Implementation Rules

- name.given is an array that captures the first name and middle name.
  1. name.`given[0]` is used to capture a person's first name.
  2. name.`given[1]` is used to capture a person's middle name.

Claim

        {
          "resource": {
            "resourceType": "Claim",
            "meta": {
              "profile": [
                "https://nhdr.gov.ph/fhir/StructureDefinition/PH-Claim"
              ]
            },
            "extension": [
              {
                "url": "https://nhdr.gov.ph/fhir/StructureDefinition/EncounterExtension",
                "valueReference": {
                  "reference": "urn:uuid:encounter"
                }
              }
            ],
            "identifier": [
              {
                "system": "https://nhdr.gov.ph/claim",
                "value": "CLAIM-0001"
              }
            ],
            "status": "active",
            "type": {
              "coding": [
                {
                  "system": "http://terminology.hl7.org/CodeSystem/claim-type",
                  "code": "institutional"
                }
              ]
            },
            "use": "claim",
            "patient": {
              "reference": "urn:uuid:patient"
            },
            "provider": {
              "reference": "urn:uuid:organization"
            },
            "created": "2026-03-17",
            "priority": {
              "coding": [
                {
                  "system": "http://terminology.hl7.org/CodeSystem/processpriority",
                  "code": "normal"
                }
              ]
            },
            "diagnosis": [
              {
                "sequence": 1,
                "diagnosisCodeableConcept": {
                  "text": "Hypertension"
                }
              }
            ],
            "supportingInfo": [
              {
                "sequence": 1,
                "category": { "text": "Pertinent Past Medical History" },
                "valueReference": {
                  "reference": "urn:uuid:observation-1"
                }
              },
              {
                "sequence": 2,
                "category": { "text": "Signs and Symptoms" },
                "valueReference": {
                  "reference": "urn:uuid:observation-2"
                }
              },
              {
                "sequence": 3,
                "category": { "text": "Physical Examination" },
                "valueReference": {
                  "reference": "urn:uuid:observation-3"
                }
              }
            ],
            "procedure": [
              {
                "sequence": 1,
                "procedureReference": {
                  "reference": "urn:uuid:procedure"
                }
              }
            ],
            "insurance": [
              {
                "sequence": 1,
                "focal": true,
                "coverage": {
                  "reference": "urn:uuid:coverage"
                }
              }
            ],
            "item": [
              {
                "sequence": 1,
                "productOrService": {
                  "text": "General Ward"
                },
                "quantity": {
                  "value": 1
                },
                "net": {
                  "value": 1000,
                  "currency": "PHP"
                }
              }
            ],
            "referral": {
              "reference": "urn:uuid:servicerequest"
            },
            "prescription": {
              "reference": "urn:uuid:medicationrequest"
            }
          },
          "request": {
            "method": "POST",
            "url": "Claim"
          }
        }