Claim-example-vision-glasses.json

Glasses Claim

{
  "resourceType": "Claim",
  "id": "660151",
  "text": {
    "status": "generated",
    "div": "<div xmlns=\"http://www.w3.org/1999/xhtml\">A human-readable rendering of the Vision Claim for Glasses</div>"
  },
  "identifier": [
    {
      "system": "http://happysight.com/claim",
      "value": "6612346"
    }
  ],
  "status": "active",
  "type": {
    "system": "http://hl7.org/fhir/ex-claimtype",
    "code": "vision"
  },
  "created": "2014-08-16",
  "insurerReference": {
    "reference": "Organization/2"
  },
  "organizationReference": {
    "reference": "Organization/1"
  },
  "use": "complete",
  "priority": {
    "code": "normal"
  },
  "prescriptionReference": {
    "reference": "http://www.optdocs.com/prescription/12345"
  },
  "payee": {
    "type": {
      "code": "provider"
    }
  },
  "diagnosis": [
    {
      "sequence": 1,
      "diagnosis": {
        "code": "654321"
      }
    }
  ],
  "patientReference": {
    "reference": "Patient/1"
  },
  "coverage": [
    {
      "sequence": 1,
      "focal": true,
      "coverageReference": {
        "reference": "Coverage/9876B1"
      }
    }
  ],
  "item": [
    {
      "sequence": 1,
      "careTeam": [
        {
          "providerReference": {
            "reference": "Practitioner/example"
          }
        }
      ],
      "service": {
        "system": "http://hl7.org/fhir/ex-visionservice",
        "code": "glasses"
      },
      "servicedDate": "2014-08-16",
      "unitPrice": {
        "value": 214.00,
        "system": "urn:iso:std:iso:4217",
        "code": "USD"
      },
      "net": {
        "value": 214.00,
        "system": "urn:iso:std:iso:4217",
        "code": "USD"
      },
      "detail": [
        {
          "sequence": 1,
          "service": {
            "system": "http://hl7.org/fhir/ex-visionservice",
            "code": "frame"
          },
          "unitPrice": {
            "value": 100.00,
            "system": "urn:iso:std:iso:4217",
            "code": "USD"
          },
          "net": {
            "value": 100.00,
            "system": "urn:iso:std:iso:4217",
            "code": "USD"
          }
        },
        {
          "sequence": 2,
          "service": {
            "system": "http://hl7.org/fhir/ex-visionservice",
            "code": "lens"
          },
          "quantity": {
            "value": 2
          },
          "unitPrice": {
            "value": 50.00,
            "system": "urn:iso:std:iso:4217",
            "code": "USD"
          },
          "net": {
            "value": 100.00,
            "system": "urn:iso:std:iso:4217",
            "code": "USD"
          }
        },
        {
          "sequence": 3,
          "service": {
            "system": "http://hl7.org/fhir/ex-visionservice",
            "code": "fst"
          },
          "unitPrice": {
            "value": 200.00,
            "system": "urn:iso:std:iso:4217",
            "code": "USD"
          },
          "factor": 0.07,
          "net": {
            "value": 14.00,
            "system": "urn:iso:std:iso:4217",
            "code": "USD"
          }
        }
      ]
    }
  ]
}