---
type: "example"
title: "Claim Example: claim-example-cms1500-medical"
resource: "Claim"
example: "claim-example-cms1500-medical"
---
# Claim Example: claim-example-cms1500-medical

## Narrative

A human-readable rendering of a CMS 1500 Claim

## Example XML



```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>
```