Claim-example.xml

Simple dental Claim (id = "100150")

<Claim xmlns="http://hl7.org/fhir">
  <id value="100150"/>

  <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="12345"/>
  </identifier>
 
  <created value="2014-08-16"/>

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

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

  <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>
 
  <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>
     <code value="service"/>
   </type>
   <providerReference>
     <reference value="Practitioner/example"/>
   </providerReference>
   <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>