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Resource "MED-00050" Version "1" (Claim)

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XML or JSON representation . provenance for this resource

A human-readable rendering of a CMS 1500 Claim

{
  "resourceType" : "Claim",
  "id" : "MED-00050",
  "meta" : {
    "versionId" : "1",
    "lastUpdated" : "2018-12-14T02:01:34.098Z"
  },
  "text" : {
    "status" : "generated",
    "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\">A human-readable rendering of a CMS 1500 Claim</div>"
  },
  "contained" : [
    {
      "resourceType" : "Patient",
      "id" : "patient-1",
      "name" : [
        {
          "use" : "official",
          "family" : "Ashcraft",
          "given" : [
            "Alvina"
          ]
        }
      ],
      "gender" : "female",
      "birthDate" : "1954-06-11",
      "address" : [
        {
          "use" : "home",
          "line" : [
            "123 Main Street"
          ],
          "city" : "Portland",
          "state" : "OR",
          "postalCode" : "97125",
          "country" : "USA"
        }
      ]
    },
    {
      "resourceType" : "Coverage",
      "id" : "coverage-1",
      "identifier" : [
        {
          "system" : "http://benefitsinc.com/certificate",
          "value" : "10138556"
        }
      ],
      "status" : "active",
      "type" : {
        "coding" : [
          {
            "system" : "http://terminology.hl7.org/CodeSystem/v3-ActCode",
            "code" : "HIP",
            "display" : "health insurance plan policy"
          }
        ]
      },
      "subscriber" : {
        "reference" : "#patient-1"
      },
      "beneficiary" : {
        "reference" : "#patient-1"
      },
      "relationship" : {
        "coding" : [
          {
            "code" : "self"
          }
        ]
      },
      "period" : {
        "start" : "2015-01-01T00:00:00-07:00",
        "end" : "2016-01-01T00:00:00-07:00"
      },
      "payor" : [
        {
          "identifier" : {
            "system" : "http://www.bindb.com/bin",
            "value" : "123456"
          },
          "display" : "Humana Inc."
        }
      ],
      "class" : [
        {
          "type" : {
            "coding" : [
              {
                "system" : "http://terminology.hl7.org/CodeSystem/coverage-class",
                "code" : "group"
              }
            ]
          },
          "value" : "80902206"
        }
      ]
    }
  ],
  "identifier" : [
    {
      "system" : "http://CedarArmsMedicalCenter.com/claim",
      "value" : "MED-00050"
    }
  ],
  "status" : "active",
  "type" : {
    "coding" : [
      {
        "system" : "http://terminology.hl7.org/CodeSystem/claim-type",
        "code" : "institutional"
      }
    ]
  },
  "subType" : {
    "coding" : [
      {
        "system" : "https://www.cms.gov/codes/billtype",
        "code" : "831",
        "display" : "Hospital Outpatient Surgery performed in an Ambulatory ​Surgical Center"
      }
    ]
  },
  "use" : "claim",
  "patient" : {
    "reference" : "#patient-1"
  },
  "created" : "2015-10-16T00:00:00-07:00",
  "insurer" : {
    "identifier" : {
      "system" : "http://www.bindb.com/bin",
      "value" : "123456"
    },
    "display" : "Humana Inc."
  },
  "provider" : {
    "reference" : "Organization/1"
  },
  "priority" : {
    "coding" : [
      {
        "code" : "normal"
      }
    ]
  },
  "payee" : {
    "type" : {
      "coding" : [
        {
          "system" : "http://terminology.hl7.org/CodeSystem/payeetype",
          "code" : "provider"
        }
      ]
    },
    "party" : {
      "reference" : "Organization/1"
    }
  },
  "careTeam" : [
    {
      "sequence" : 1,
      "provider" : {
        "reference" : "Practitioner/example"
      }
    }
  ],
  "supportingInfo" : [
    {
      "sequence" : 1,
      "category" : {
        "coding" : [
          {
            "system" : "http://terminology.hl7.org/CodeSystem/claiminformationcategory",
            "code" : "hospitalized"
          }
        ]
      },
      "timingPeriod" : {
        "start" : "2015-10-01T00:00:00-07:00",
        "end" : "2015-10-05T00:00:00-07:00"
      }
    },
    {
      "sequence" : 2,
      "category" : {
        "coding" : [
          {
            "system" : "http://terminology.hl7.org/CodeSystem/claiminformationcategory",
            "code" : "discharge"
          }
        ]
      },
      "code" : {
        "coding" : [
          {
            "system" : "https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/SE0801.pdf",
            "code" : "01",
            "display" : "Discharge to Home or Self Care"
          }
        ]
      }
    }
  ],
  "diagnosis" : [
    {
      "sequence" : 1,
      "diagnosisCodeableConcept" : {
        "coding" : [
          {
            "system" : "http://hl7.org/fhir/sid/icd-10",
            "code" : "M96.1",
            "display" : "Postlaminectomy syndrome"
          }
        ]
      }
    },
    {
      "sequence" : 2,
      "diagnosisCodeableConcept" : {
        "coding" : [
          {
            "system" : "http://hl7.org/fhir/sid/icd-10",
            "code" : "G89.4",
            "display" : "Chronic pain syndrome"
          }
        ]
      }
    },
    {
      "sequence" : 3,
      "diagnosisCodeableConcept" : {
        "coding" : [
          {
            "system" : "http://hl7.org/fhir/sid/icd-10",
            "code" : "M53.88",
            "display" : "Other specified dorsopathies, sacral and sacrococcygeal region"
          }
        ]
      }
    },
    {
      "sequence" : 4,
      "diagnosisCodeableConcept" : {
        "coding" : [
          {
            "system" : "http://hl7.org/fhir/sid/icd-10",
            "code" : "M47.816",
            "display" : "Spondylosis without myelopathy or radiculopathy, lumbar region"
          }
        ]
      }
    }
  ],
  "insurance" : [
    {
      "sequence" : 1,
      "focal" : true,
      "identifier" : {
        "system" : "http://CedarArmsMedicalCenter.com/claim",
        "value" : "MED-00050"
      },
      "coverage" : {
        "reference" : "#coverage-1"
      }
    }
  ],
  "item" : [
    {
      "sequence" : 1,
      "careTeamSequence" : [
        "1"
      ],
      "diagnosisSequence" : [
        "2",
        "4"
      ],
      "informationSequence" : [
        "1"
      ],
      "productOrService" : {
        "coding" : [
          {
            "system" : "http://www.ama-assn.org/go/cpt",
            "code" : "62264",
            "display" : "Surgical Procedures on the Spine and Spinal Cord"
          }
        ]
      },
      "servicedDate" : "2015-10-13",
      "locationCodeableConcept" : {
        "coding" : [
          {
            "system" : "https://www.cms.gov/medicare/coding/place-of-service-codes/place_of_service_code_set.html",
            "code" : "24",
            "display" : "Ambulatory Surgical Center"
          }
        ]
      },
      "unitPrice" : {
        "value" : 12500.00,
        "currency" : "USD"
      },
      "net" : {
        "value" : 12500.00,
        "currency" : "USD"
      }
    }
  ],
  "total" : {
    "value" : 12500.00,
    "currency" : "USD"
  }
}