Claim Example: claim-example-cms1500-medical

Narrative

A human-readable rendering of a CMS 1500 Claim

Example XML

<?xml version="1.0" encoding="UTF-8"?>
<Claim xmlns="http://hl7.org/fhir" xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance" >
    <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"/>

    <subject>
        <reference value="#patient-1"/>
    </subject>

    <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/downloads/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>