Oralhealthclaim-example.xml

Simple dental Claim (id = "100150")

Raw XML

<OralHealthClaim xmlns="http://hl7.org/fhir">
  <id value="100150"/>
  <text>
    <status value="generated"/>
    <div xmlns="http://www.w3.org/1999/xhtml"><!-- Snipped for brevity --></div>
  </text>
  <identifier>
    <system value="http://happyvalley.com/claims"/>
    <value value="12345"/>
  </identifier>
  <created value="2014-08-16"/>
  <target>
    <reference value="Organization/2"/>
  </target>
  <organization>
    <reference value="Organization/1"/>
  </organization>
  <use value="complete"/>
  <priority>
    <code value="normal"/>
  </priority>
  <payee>
    <type>
      <code value="provider"/>
    </type>
  </payee>
  <diagnosis>
    <sequence value="1"/>
    <diagnosis>
      <code value="123456"/>
    </diagnosis>
  </diagnosis>
  <patient>
    <reference value="Patient/1"/>
  </patient>
  <coverage>
    <sequence value="1"/>
    <focal value="true"/>
    <coverage>
      <reference value="Coverage/9876B1"/>
    </coverage>
    <relationship>
      <code value="self"/>
    </relationship>
  </coverage>
  <item>
    <sequence value="1"/>
    <type>
      <code value="service"/>
    </type>
    <provider>
      <reference value="Practitioner/1"/>
    </provider>
    <service>
      <code value="1200"/>
    </service>
    <serviceDate value="2014-08-16"/>
    <unitPrice>
      <value value="135.57"/>
      <system value="urn:std:iso:4217"/>
      <code value="USD"/>
    </unitPrice>
    <net>
      <value value="135.57"/>
      <system value="urn:std:iso:4217"/>
      <code value="USD"/>
    </net>
  </item>
</OralHealthClaim>