This page is part of the FHIR Specification (v1.6.0: STU 3 Ballot 4). 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
Glasses Claim (id = "660151")
<Claim xmlns="http://hl7.org/fhir"> <id value="660151"/> <text> <status value="generated"/> <div xmlns="http://www.w3.org/1999/xhtml">A human-readable rendering of the Vision Claim for Glasses</div> </text> <identifier> <system value="http://happysight.com/claim"/> <value value="6612346"/> </identifier> <status value="active"/> <type> <system value="http://hl7.org/fhir/ex-claimtype"/> <code value="vision"/> </type> <created value="2014-08-16"/> <insurerReference> <reference value="Organization/2"/> </insurerReference> <organizationReference> <reference value="Organization/1"/> </organizationReference> <use value="complete"/> <priority> <code value="normal"/> </priority> <prescriptionReference> <reference value="http://www.optdocs.com/prescription/12345"/> </prescriptionReference> <payee> <type> <code value="provider"/> </type> </payee> <diagnosis> <sequence value="1"/> <diagnosis> <code value="654321"/> </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="group"/> </type --> <careTeam> <providerReference> <reference value="Practitioner/example"/> </providerReference> </careTeam> <service> <system value="http://hl7.org/fhir/ex-visionservice"/> <code value="glasses"/> </service> <servicedDate value="2014-08-16"/> <unitPrice> <value value="214.00"/> <system value="urn:iso:std:iso:4217"/> <code value="USD"/> </unitPrice> <net> <value value="214.00"/> <system value="urn:iso:std:iso:4217"/> <code value="USD"/> </net> <detail> <sequence value="1"/> <!-- type> <code value="product"/> </type --> <service> <system value="http://hl7.org/fhir/ex-visionservice"/> <code value="frame"/> </service> <unitPrice> <value value="100.00"/> <system value="urn:iso:std:iso:4217"/> <code value="USD"/> </unitPrice> <net> <value value="100.00"/> <system value="urn:iso:std:iso:4217"/> <code value="USD"/> </net> </detail> <detail> <sequence value="2"/> <!-- type> <code value="product"/> </type --> <service> <system value="http://hl7.org/fhir/ex-visionservice"/> <code value="lens"/> </service> <quantity> <value value="2"/> </quantity> <unitPrice> <value value="50.00"/> <system value="urn:iso:std:iso:4217"/> <code value="USD"/> </unitPrice> <net> <value value="100.00"/> <system value="urn:iso:std:iso:4217"/> <code value="USD"/> </net> </detail> <detail> <sequence value="3"/> <!-- type> <code value="tax"/> </type --> <service> <system value="http://hl7.org/fhir/ex-visionservice"/> <code value="fst"/> </service> <unitPrice> <value value="200.00"/> <system value="urn:iso:std:iso:4217"/> <code value="USD"/> </unitPrice> <factor value="0.07"/> <net> <value value="14.00"/> <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.