Claim Example: claim-example-institutional-rich

Narrative

A human-readable rendering of the 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" xsi:schemaLocation="http://hl7.org/fhir ../../schema/coverage.xsd">
    <id value="960151"/>

    <text>
        <status value="generated"/>
        <div xmlns="http://www.w3.org/1999/xhtml">A human-readable rendering of the Claim</div>
    </text>

    <identifier>
        <system value="http://happyhospital.com/claim"/>
        <value value="96123451"/>
    </identifier>

    <status value = "active"/>

    <type>
        <coding>
            <system value="http://terminology.hl7.org/CodeSystem/claim-type"/>
            <code value="institutional"/>
        </coding>
    </type>

    <use value="claim"/>

    <subject>
        <reference value="Patient/1"/>
    </subject>

    <billablePeriod>
        <start value="2014-08-15"/>
        <end value="2014-08-16"/>
    </billablePeriod>

    <created value="2014-08-16"/>

    <enterer>
        <identifier>
            <system value="http://jurisdiction.org/facilities/HOSP1234/users"/>
            <value value="UC1234"/>
        </identifier>
    </enterer>

    <insurer>
        <reference value="Organization/2"/>
    </insurer>

    <provider>
        <identifier>
            <system value="http://npid.org/providerid"/>
            <value value="NJ12345"/>
        </identifier>
    </provider>

    <priority>
        <coding>
            <code value="normal"/>
        </coding>
    </priority>

    <payee>
        <type>
            <coding>
                <code value="provider"/>
            </coding>
        </type>
    </payee>

    <facility>
        <identifier>
            <system value="http://jurisdiction.org/facilities"/>
            <value value="HOSP1234"/>
        </identifier>
    </facility>

    <diagnosisRelatedGroup>
        <coding>
            <system value="http://terminology.hl7.org/CodeSystem/ex-diagnosisrelatedgroup"/>
            <code value="400"/>
            <display value="Head trauma - concussion"/>
        </coding>
    </diagnosisRelatedGroup>

    <careTeam>
        <sequence value="1"/>
        <provider>
            <reference value="Practitioner/example"/>
        </provider>
        <responsible value="true"/>
        <role>
            <coding>
                <system value="http://example.org/fhir/CodeSystem/claim-careteamrole"/>
                <code value="primary"/>
            </coding>
        </role>
        <specialty>
            <coding>
                <system value="http://example.org/fhir/CodeSystem/provider-qualification"/>
                <code value="physician"/>
            </coding>
        </specialty>
    </careTeam>

    <supportingInfo>
        <sequence value="1"/>
        <category>
            <coding>
                <system value="http://terminology.hl7.org/CodeSystem/claiminformationcategory"/>
                <code value="employmentimpacted"/>
            </coding>
        </category>
        <timingPeriod>
            <start value="2014-08-16"/>
            <end value="2014-08-16"/>
        </timingPeriod>
    </supportingInfo>

    <supportingInfo>
        <sequence value="2"/>
        <category>
            <coding>
                <system value="http://terminology.hl7.org/CodeSystem/claiminformationcategory"/>
                <code value="hospitalized"/>
            </coding>
        </category>
        <timingPeriod>
            <start value="2014-08-15"/>
            <end value="2014-08-16"/>
        </timingPeriod>
    </supportingInfo>

    <diagnosis>
        <sequence value="1"/>
        <diagnosisCodeableConcept>
            <coding>
                <code value="654456"/>
            </coding>
        </diagnosisCodeableConcept>
        <type>
            <coding>
                <system value="http://terminology.hl7.org/CodeSystem/ex-diagnosistype"/>
                <code value="admitting"/>
            </coding>
        </type>

    </diagnosis>

    <insurance>
        <sequence value="1"/>
        <focal value="true"/>
        <coverage>
            <reference value="Coverage/9876B1"/>
        </coverage>
        <businessArrangement value="BA987123"/>
        <preAuthRef value="PA2014G56473"/>
    </insurance>

    <accident>
        <date value="2014-07-09"/>
        <type>
            <coding>
                <system value="http://terminology.hl7.org/CodeSystem/v3-ActIncidentCode"/>
                <code value="SPT"/>
                <display value="Sporting Accident"/>
            </coding>
        </type>
        <locationAddress>
            <text value="Grouse Mountain Ski Hill"/>
        </locationAddress>
    </accident>

    <item>
        <sequence value="1"/>
        <careTeamSequence value="1"/>
        <productOrService>
            <coding>
                <system value="http://hl7.org/fhir/ex-serviceproduct"/>
                <code value="exam"/>
            </coding>
        </productOrService>
        <servicedDate value="2014-08-16"/>
        <unitPrice>
            <value value="125.00"/>
            <currency value="USD"/>
        </unitPrice>
        <net>
            <value value="125.00"/>
            <currency value="USD"/>
        </net>
    </item>

    <total>
        <value value="125.00"/>
        <currency value="USD"/>
    </total>
</Claim>