STU 3 Candidate
This page is part of the FHIR Specification (v1.4.0: STU 3 Ballot 3). The current version which supercedes this version is 5.0.0. For a full list of available versions, see the Directory of published versions . Page versions: R5 R4B R4 R3 R2
Claim-example-oral-orthoplan.xml

Raw XML (canonical form)
PreAuthorization with Orthodontic Treatment Plan (id = "100153")
<Claim xmlns="http://hl7.org/fhir">
  <id value="100153"/>

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

  <type value="oral"/>
  
  <identifier>
    <system value="http://happyvalley.com/claim"/>
    <value value="12355"/>
  </identifier>
 
  <created value="2015-03-16"/>

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

  <organizationReference>
    <reference value="Organization/1"/>
  </organizationReference>

  <use value="proposed"/>

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

  <fundsReserve>
    <code value="provider"/>
  </fundsReserve>
  
  <payee>
    <type>
      <code value="provider"/>
    </type>
  </payee>
 
  <diagnosis>
    <sequence value="1"/>
    <diagnosis>
    <system value="http://hl7.org/fhir/sid/icd-10"/>
      <code value="123457"/>
    </diagnosis>
  </diagnosis>
 
  <patientReference>
    <reference value="Patient/1"/>
  </patientReference>
 
  <coverage>
    <sequence value="1"/>
    <focal value="true"/>
    <coverageReference>
      <reference value="Coverage/9876B1"/>
    </coverageReference>
  </coverage>
  
 <item>
   <sequence value="1"/>
   <type>
     <system value="http://hl7.org/fhir/v3/ActCode"/>
     <code value="FRAMEING"/> <!--   was group changed by GG to be valid   -->
   </type>
   <providerReference>
     <reference value="Practitioner/example"/>
   </providerReference>
   <diagnosisLinkId value="1"/>
   <service>
     <system value="http://hl7.org/fhir/oralservicecodes"/>
     <code value="ORTHPLAN"/>
   </service>
   <servicedDate value="2015-05-16"/>  <!--   Start Date   -->
   <unitPrice>
     <value value="9000.00"/>
     <system value="urn:iso:std:iso:4217"/>
     <code value="USD"/> 
   </unitPrice> 
   <net>
     <value value="9000.00"/>
     <system value="urn:iso:std:iso:4217"/>
     <code value="USD"/> 
   </net> 
   <detail>
     <sequence value="1"/> <!--   Exam Fee   -->
     <type>
       <system value="http://hl7.org/fhir/v3/ActCode"/>
       <code value="CSINV"/> <!--   was service, changed by GG to be valid   -->
     </type>
     <service>
       <system value="http://hl7.org/fhir/oralservicecodes"/>
       <code value="ORTHOEXAM"/>
     </service>
     <unitPrice>
       <value value="1000.00"/>
       <system value="urn:iso:std:iso:4217"/>
       <code value="USD"/> 
     </unitPrice> 
     <net>
       <value value="1000.00"/>
       <system value="urn:iso:std:iso:4217"/>
       <code value="USD"/> 
     </net> 
   </detail>
   <detail>
     <sequence value="2"/> <!--   Diagnostic Fee   -->
     <type>
       <system value="http://hl7.org/fhir/v3/ActCode"/>
       <code value="CSINV"/> <!--   was service, changed by GG to be valid   -->
     </type>
     <service>
       <system value="http://hl7.org/fhir/oralservicecodes"/>
       <code value="ORTHODIAG"/>
     </service>
     <unitPrice>
       <value value="1500.00"/>
       <system value="urn:iso:std:iso:4217"/>
       <code value="USD"/> 
     </unitPrice> 
     <net>
       <value value="1500.00"/>
       <system value="urn:iso:std:iso:4217"/>
       <code value="USD"/> 
     </net> 
   </detail>
   <detail>
     <sequence value="3"/> <!--   Initial Payment   -->
     <type>
       <system value="http://hl7.org/fhir/v3/ActCode"/>
       <code value="CSINV"/> <!--   was service, changed by GG to be valid   -->
     </type>
     <service>
       <system value="http://hl7.org/fhir/oralservicecodes"/>
       <code value="ORTHOINITIAL"/>
     </service>
     <unitPrice>
       <value value="500.00"/>
       <system value="urn:iso:std:iso:4217"/>
       <code value="USD"/> 
     </unitPrice> 
     <net>
       <value value="500.00"/>
       <system value="urn:iso:std:iso:4217"/>
       <code value="USD"/> 
     </net> 
   </detail>
   <detail>
     <sequence value="4"/> <!--   Duration in Months   -->
     <type>
       <system value="http://hl7.org/fhir/v3/ActCode"/>
       <code value="CSINV"/> <!--   was service, changed by GG to be valid   -->
     </type>
     <service>
       <system value="http://hl7.org/fhir/oralservicecodes"/>
       <code value="ORTHOMONTHS"/>
     </service>
     <quantity>
       <value value="24"/>
     </quantity>  
   </detail>
   <detail>
     <sequence value="5"/> <!--   Periodic Payments   -->
     <type>
       <system value="http://hl7.org/fhir/v3/ActCode"/>
       <code value="CSINV"/> <!--   was service, changed by GG to be valid   -->
     </type>
     <service>
       <system value="http://hl7.org/fhir/oralservicecodes"/>
       <code value="ORTHOPERIODIC"/>
     </service>
     <quantity>
       <value value="24"/>
     </quantity>  
     <unitPrice>
       <value value="250.00"/>
       <system value="urn:iso:std:iso:4217"/>
       <code value="USD"/> 
     </unitPrice> 
     <net>
       <value value="250.00"/>
       <system value="urn:iso:std:iso:4217"/>
       <code value="USD"/> 
     </net> 
   </detail>
  </item>

  <item>
   <sequence value="2"/>
   <type>
     <code value="service"/>
   </type>
   <providerReference>
     <reference value="Practitioner/example"/>
   </providerReference>
   <service>
     <system value="http://hl7.org/fhir/oralservicecodes"/>
     <code value="21211"/>
   </service>
   <servicedDate value="2014-08-16"/>
   <unitPrice>
     <value value="105.00"/>
     <system value="urn:iso:std:iso:4217"/>
     <code value="USD"/> 
   </unitPrice> 
   <net>
     <value value="105.00"/>
     <system value="urn:iso:std:iso:4217"/>
     <code value="USD"/> 
   </net> 
   <bodySite>
     <system value="http://fdi.org/fhir/oraltoothcodes"/>
     <code value="21"/>
   </bodySite>
   <subSite>
     <system value="http://fdi.org/fhir/oralsurfacecodes"/>
     <code value="L"/>
   </subSite>
  </item>

  <item>
   <sequence value="3"/>
   <type>
     <code value="group"/>
   </type>
   <providerReference>
     <reference value="Practitioner/example"/>
   </providerReference>
   <service>
     <system value="http://hl7.org/fhir/oralservicecodes"/>
     <code value="27211"/>
   </service>
   <servicedDate value="2014-08-16"/>
   <unitPrice>
     <value value="1100.00"/>
     <system value="urn:iso:std:iso:4217"/>
     <code value="USD"/> 
   </unitPrice> 
   <net>
     <value value="1100.00"/>
     <system value="urn:iso:std:iso:4217"/>
     <code value="USD"/> 
   </net> 
   <bodySite>
     <system value="http://fdi.org/fhir/oraltoothcodes"/>
     <code value="36"/>
   </bodySite>
   <detail>
     <sequence value="1"/>
     <type>
       <code value="service"/>
     </type>
     <service>
       <system value="http://hl7.org/fhir/oralservicecodes"/>
       <code value="27211"/>
     </service>
     <unitPrice>
       <value value="750.00"/>
       <system value="urn:iso:std:iso:4217"/>
       <code value="USD"/> 
     </unitPrice> 
     <net>
       <value value="750.00"/>
       <system value="urn:iso:std:iso:4217"/>
       <code value="USD"/> 
     </net> 
   </detail>
   <detail>
     <sequence value="2"/>
     <type>
       <code value="service"/>
     </type>
     <service>
       <system value="http://hl7.org/fhir/oralservicecodes"/>
       <code value="lab"/>
     </service>
     <unitPrice>
       <value value="350.00"/>
       <system value="urn:iso:std:iso:4217"/>
       <code value="USD"/> 
     </unitPrice> 
     <net>
       <value value="350.00"/>
       <system value="urn:iso:std:iso:4217"/>
       <code value="USD"/> 
     </net> 
   </detail>
  </item>

</Claim>
Usage note: every effort has been made to ensure that the examples are correct and useful, but they are not a normative part of the specification.