Claim-example-institutional.xml

Simple Institutional Service Claim (id = "960150")

<Claim xmlns="http://hl7.org/fhir">
 <id value="960150"/>

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

  <type value="institutional"/>
  
  <identifier>
    <system value="http://happyhospital.com/claim"/>
    <value value="9612345"/>
 </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>

 <entererIdentifier>
    <system value="http://jurisdiction.org/facilities/HOSP1234/users"/>
    <value value="UC1234"/>
</entererIdentifier>

 <facilityIdentifier>
    <system value="http://jurisdiction.org/facilities"/>
    <value value="HOSP1234"/>
</facilityIdentifier>
 
 <payee>
   <type>
     <code value="provider"/>
   </type>
 </payee>
 
  <diagnosis>
    <sequence value="1"/>
  <diagnosis>
    <code value="654456"/>
    </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>
     <system value="http://hl7.org/fhir/ex-serviceproduct"/>
     <code value="exam"/> 
   </service>
   <servicedDate value="2014-08-16"/>
   <unitPrice>
      <value value="125.00"/>
    <system value="urn:iso:std:iso:4217"/>
      <code value="USD"/> 
   </unitPrice> 
   <net>
      <value value="125.00"/>
    <system value="urn:iso:std:iso:4217"/>
      <code value="USD"/> 
   </net> 
  </item>

  <total>
    <value value="125.00"/>
  <system value="urn:iso:std:iso:4217"/>
    <code value="USD"/>  
  </total>
</Claim>