Claim-example-oral-contained.json

SOA Dental Claim

{
  "resourceType": "Claim",
  "id": "100152",
  "text": {
    "status": "generated",
    "div": "<div xmlns=\"http://www.w3.org/1999/xhtml\">A human-readable rendering of the Oral Health Claim</div>"
  },
  "contained": [
    {
      "resourceType": "Organization",
      "id": "organization-1",
      "identifier": [
        {
          "system": "http://www.jurisdiction.com/oralhealthoffices",
          "value": "3456"
        }
      ]
    },
    {
      "resourceType": "Organization",
      "id": "organization-2",
      "identifier": [
        {
          "system": "http://www.bindb.com/bin",
          "value": "123456"
        }
      ]
    },
    {
      "resourceType": "Practitioner",
      "id": "practitioner-1",
      "identifier": [
        {
          "system": "http://www.jurisdiction.com/oralhealthproviders",
          "value": "123456789"
        }
      ]
    },
    {
      "resourceType": "Patient",
      "id": "patient-1",
      "name": [
        {
          "use": "official",
          "family": [
            "Donald"
          ],
          "given": [
            "Duck"
          ]
        }
      ],
      "gender": "male",
      "birthDate": "1986-05-17",
      "address": [
        {
          "use": "home",
          "line": [
            "1234 Main Street"
          ],
          "city": "Vancouver",
          "postalCode": "V2H1Y3",
          "country": "CAD"
        }
      ]
    },
    {
      "resourceType": "Coverage",
      "id": "coverage-1",
      "status": "active",
      "issuerReference": {
        "reference": "#organization-2"
      },
      "type": {
        "system": "http://hl7.org/fhir/v3/ActCode",
        "code": "EHCPOL"
      },
      "planholderReference": {
        "reference": "#patient-1"
      },
      "beneficiaryReference": {
        "reference": "#patient-1"
      },
      "relationship": {
        "code": "self"
      },
      "identifier": [
        {
          "system": "http://benefitsinc.com/certificate",
          "value": "12345"
        }
      ],
      "plan": "CBI35",
      "subPlan": "123",
      "dependent": 1,
      "sequence": 1
    }
  ],
  "identifier": [
    {
      "system": "http://happyvalley.com/claim",
      "value": "12347"
    }
  ],
  "status": "active",
  "type": {
    "system": "http://hl7.org/fhir/ex-claimtype",
    "code": "oral"
  },
  "created": "2014-08-16",
  "insurerReference": {
    "reference": "#organization-2"
  },
  "organizationReference": {
    "reference": "#organization-1"
  },
  "use": "complete",
  "priority": {
    "code": "normal"
  },
  "payee": {
    "type": {
      "code": "provider"
    }
  },
  "diagnosis": [
    {
      "sequence": 1,
      "diagnosis": {
        "code": "123456"
      }
    }
  ],
  "patientReference": {
    "reference": "#patient-1"
  },
  "coverage": [
    {
      "sequence": 1,
      "focal": true,
      "coverageReference": {
        "reference": "#coverage-1"
      }
    }
  ],
  "item": [
    {
      "sequence": 1,
      "careTeam": [
        {
          "providerReference": {
            "reference": "#practitioner-1"
          }
        }
      ],
      "service": {
        "code": "1200"
      },
      "servicedDate": "2014-08-16",
      "unitPrice": {
        "value": 135.57,
        "system": "urn:iso:std:iso:4217",
        "code": "USD"
      },
      "net": {
        "value": 135.57,
        "system": "urn:iso:std:iso:4217",
        "code": "USD"
      }
    }
  ]
}