FHIR Implementation Guide for HCX
0.8.0 - CI Build

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: HCX Claim example - JSON Representation

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{
  "resourceType" : "Claim",
  "id" : "example-01",
  "meta" : {
    "versionId" : "1",
    "lastUpdated" : "2020-10-07T03:26:09.060+00:00",
    "source" : "#BHZcRrcF4oS0JQ42"
  },
  "text" : {
    "status" : "generated",
    "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p><b>Generated Narrative: Claim</b><a name=\"example-01\"> </a></p><div style=\"display: inline-block; background-color: #d9e0e7; padding: 6px; margin: 4px; border: 1px solid #8da1b4; border-radius: 5px; line-height: 60%\"><p style=\"margin-bottom: 0px\">Resource Claim &quot;example-01&quot; Version &quot;1&quot; Updated &quot;2020-10-07 03:26:09+0000&quot; </p><p style=\"margin-bottom: 0px\">Information Source: #BHZcRrcF4oS0JQ42!</p></div><p><b>identifier</b>: id:\u00a0dc82673b-8c71-29js-8a17-16dj3i20352n</p><p><b>status</b>: active</p><p><b>type</b>: Institutional <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"http://terminology.hl7.org/5.0.0/CodeSystem-claim-type.html\">Claim Type Codes</a>#institutional)</span></p><p><b>use</b>: claim</p><p><b>patient</b>: <span/></p><p><b>billablePeriod</b>: 1979-02-27 16:01:08-0500 --&gt; 1979-02-28 16:01:08-0500</p><p><b>created</b>: 1979-02-28 16:01:08-0500</p><p><b>insurer</b>: <span/></p><p><b>provider</b>: <span/></p><p><b>priority</b>: Normal <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"http://terminology.hl7.org/5.0.0/CodeSystem-processpriority.html\">Process Priority Codes</a>#normal)</span></p><h3>Payees</h3><table class=\"grid\"><tr><td>-</td><td><b>Type</b></td><td><b>Party</b></td></tr><tr><td>*</td><td>Provider <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"http://terminology.hl7.org/5.0.0/CodeSystem-payeetype.html\">Claim Payee Type Codes</a>#provider)</span></td><td><span/></td></tr></table><h3>CareTeams</h3><table class=\"grid\"><tr><td>-</td><td><b>Sequence</b></td><td><b>Provider</b></td></tr><tr><td>*</td><td>1</td><td><span/></td></tr></table><blockquote><p><b>procedure</b></p><p><b>sequence</b>: 1</p><p><b>procedure</b>: PROC-1 <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"http://hl7.org/fhir/R4/codesystem-icd-10-procedures.html\">ICD-10 Procedure Codes</a>#123001)</span></p></blockquote><blockquote><p><b>procedure</b></p><p><b>sequence</b>: 2</p><p><b>procedure</b>: PROC-2 <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"http://hl7.org/fhir/R4/codesystem-icd-10-procedures.html\">ICD-10 Procedure Codes</a>#123002)</span></p></blockquote><blockquote><p><b>procedure</b></p><p><b>sequence</b>: 3</p><p><b>procedure</b>: PROC-3 <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"http://hl7.org/fhir/R4/codesystem-icd-10-procedures.html\">ICD-10 Procedure Codes</a>#123003)</span></p></blockquote><h3>Insurances</h3><table class=\"grid\"><tr><td>-</td><td><b>Sequence</b></td><td><b>Focal</b></td><td><b>Coverage</b></td></tr><tr><td>*</td><td>1</td><td>true</td><td><span>: Cigna Health</span></td></tr></table><blockquote><p><b>item</b></p><p><b>sequence</b>: 1</p><p><b>productOrService</b>: Encounter for problem <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"https://browser.ihtsdotools.org/\">SNOMED CT</a>#185347001)</span></p></blockquote><blockquote><p><b>item</b></p><p><b>sequence</b>: 2</p><p><b>procedureSequence</b>: 1</p><p><b>productOrService</b>: Hearing examination (procedure) <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"https://browser.ihtsdotools.org/\">SNOMED CT</a>#398171003)</span></p><h3>Nets</h3><table class=\"grid\"><tr><td>-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td>*</td><td>516.65</td><td>USD</td></tr></table></blockquote><blockquote><p><b>item</b></p><p><b>sequence</b>: 3</p><p><b>procedureSequence</b>: 2</p><p><b>productOrService</b>: Combined chemotherapy and radiation therapy (procedure) <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"https://browser.ihtsdotools.org/\">SNOMED CT</a>#703423002)</span></p><h3>Nets</h3><table class=\"grid\"><tr><td>-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td>*</td><td>16924.49</td><td>USD</td></tr></table></blockquote><blockquote><p><b>item</b></p><p><b>sequence</b>: 4</p><p><b>procedureSequence</b>: 3</p><p><b>productOrService</b>: High resolution computed tomography of chest without contrast (procedure) <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"https://browser.ihtsdotools.org/\">SNOMED CT</a>#16335031000119103)</span></p><h3>Nets</h3><table class=\"grid\"><tr><td>-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td>*</td><td>516.65</td><td>USD</td></tr></table></blockquote><h3>Totals</h3><table class=\"grid\"><tr><td>-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td>*</td><td>129.16</td><td>USD</td></tr></table></div>"
  },
  "identifier" : [
    {
      "system" : "https://www.tmh.in/claim-request",
      "value" : "dc82673b-8c71-29js-8a17-16dj3i20352n"
    }
  ],
  "status" : "active",
  "type" : {
    "coding" : [
      {
        "system" : "http://terminology.hl7.org/CodeSystem/claim-type",
        "code" : "institutional"
      }
    ]
  },
  "use" : "claim",
  "patient" : {
    "id" : "RVH1003",
    "identifier" : {
      "type" : {
        "coding" : [
          {
            "system" : "http://terminology.hl7.org/CodeSystem/v2-0203",
            "code" : "SN",
            "display" : "Subscriber Number"
          }
        ]
      },
      "system" : "http://gicofIndia.com/beneficiaries",
      "value" : "BEN-101"
    }
  },
  "billablePeriod" : {
    "start" : "1979-02-27T16:01:08-05:00",
    "end" : "1979-02-28T16:01:08-05:00"
  },
  "created" : "1979-02-28T16:01:08-05:00",
  "insurer" : {
    "id" : "GICOFINDIA",
    "identifier" : {
      "system" : "http://irdai.gov.in/insurers",
      "value" : "112"
    }
  },
  "provider" : {
    "id" : "Tmh01",
    "identifier" : {
      "system" : "http://abdm.gov.in/facilities",
      "value" : "HFR-ID-FOR-TMH"
    }
  },
  "priority" : {
    "coding" : [
      {
        "system" : "http://terminology.hl7.org/CodeSystem/processpriority",
        "code" : "normal"
      }
    ]
  },
  "payee" : {
    "type" : {
      "coding" : [
        {
          "system" : "http://terminology.hl7.org/CodeSystem/payeetype",
          "code" : "provider"
        }
      ]
    },
    "party" : {
      "id" : "Tmh02",
      "identifier" : {
        "system" : "http://abdm.gov.in/facilities",
        "value" : "HFR-ID-FOR-TMH"
      }
    }
  },
  "careTeam" : [
    {
      "sequence" : 1,
      "provider" : {
        "id" : "Tmh03",
        "identifier" : {
          "system" : "http://abdm.gov.in/facilities",
          "value" : "HFR-ID-FOR-TMH"
        }
      }
    }
  ],
  "procedure" : [
    {
      "sequence" : 1,
      "procedureCodeableConcept" : {
        "coding" : [
          {
            "system" : "http://hl7.org/fhir/sid/ex-icd-10-procedures",
            "code" : "123001"
          }
        ]
      }
    },
    {
      "sequence" : 2,
      "procedureCodeableConcept" : {
        "coding" : [
          {
            "system" : "http://hl7.org/fhir/sid/ex-icd-10-procedures",
            "code" : "123002"
          }
        ]
      }
    },
    {
      "sequence" : 3,
      "procedureCodeableConcept" : {
        "coding" : [
          {
            "system" : "http://hl7.org/fhir/sid/ex-icd-10-procedures",
            "code" : "123003"
          }
        ]
      }
    }
  ],
  "insurance" : [
    {
      "sequence" : 1,
      "focal" : true,
      "coverage" : {
        "display" : "Cigna Health"
      }
    }
  ],
  "item" : [
    {
      "sequence" : 1,
      "productOrService" : {
        "coding" : [
          {
            "system" : "http://snomed.info/sct",
            "code" : "185347001",
            "display" : "Encounter for problem"
          }
        ],
        "text" : "Encounter for problem"
      }
    },
    {
      "sequence" : 2,
      "procedureSequence" : [
        1
      ],
      "productOrService" : {
        "coding" : [
          {
            "system" : "http://snomed.info/sct",
            "code" : "398171003",
            "display" : "Hearing examination (procedure)"
          }
        ],
        "text" : "Hearing examination (procedure)"
      },
      "net" : {
        "value" : 516.65,
        "currency" : "USD"
      }
    },
    {
      "sequence" : 3,
      "procedureSequence" : [
        2
      ],
      "productOrService" : {
        "coding" : [
          {
            "system" : "http://snomed.info/sct",
            "code" : "703423002",
            "display" : "Combined chemotherapy and radiation therapy (procedure)"
          }
        ],
        "text" : "Combined chemotherapy and radiation therapy (procedure)"
      },
      "net" : {
        "value" : 16924.49,
        "currency" : "USD"
      }
    },
    {
      "sequence" : 4,
      "procedureSequence" : [
        3
      ],
      "productOrService" : {
        "coding" : [
          {
            "system" : "http://snomed.info/sct",
            "code" : "16335031000119103",
            "display" : "High resolution computed tomography of chest without contrast (procedure)"
          }
        ],
        "text" : "High resolution computed tomography of chest without contrast (procedure)"
      },
      "net" : {
        "value" : 516.65,
        "currency" : "USD"
      }
    }
  ],
  "total" : {
    "value" : 129.16,
    "currency" : "USD"
  }
}