Claim-example-oral-identifier.xml

SOA Dental Claim using identifiers (id = "100154")

<Claim xmlns="http://hl7.org/fhir">
  <id value="100154"/>
  <text>
    <status value="generated"/>
    <div xmlns="http://www.w3.org/1999/xhtml">This example assumes a national health care scheme where patients, providers and organizations
       have known business identifiers.</div>
  </text>
  
  <type value="oral"/>
  
  <identifier>
    <system value="http://happyvalley.com/claim"/>
    <value value="12347"/>
  </identifier>
  
  <created value="2014-08-16"/>
  
  <targetIdentifier>
    <system value="http://www.jurisdiction.com/insurers"/>
    <value value="123456"/>
  </targetIdentifier>
  
  <organizationIdentifier>
    <system value="http://www.jurisdiction.com/careorganizations"/>
    <value value="HOSP12345"/>
  </organizationIdentifier>
  
  <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>
  
  <patientIdentifier>
    <system value="http://www.jurisdiction.com/nationalId"/>
    <value value="123AB345"/>
  </patientIdentifier>
  
  <coverage>
    <sequence value="1"/>
    <focal value="true"/>
    <coverageIdentifier>
      <system value="http://www.jurisdiction.com/nationalplan"/>
      <value value="123AB345"/>
    </coverageIdentifier>
  </coverage>
  
  <item>
    <sequence value="1"/>
    <type>
      <code value="service"/>
    </type>
    <providerIdentifier>
      <system value="http://www.jurisdiction.com/providerId"/>
      <value value="MD98765"/>
    </providerIdentifier>
    <service>
      <code value="1200"/>
    </service>
    <servicedDate value="2014-08-16"/>
    <unitPrice>
      <value value="135.57"/>
      <system value="urn:iso:std:iso:4217"/>
      <code value="USD"/>
    </unitPrice>
    <net>
      <value value="135.57"/>
      <system value="urn:iso:std:iso:4217"/>
      <code value="USD"/>
    </net>
  </item>
</Claim>