Claim-example-oral-contained.xml

SOA Dental Claim (Contained) (id = "100152")

<Claim xmlns="http://hl7.org/fhir">
  <id value="100152"/>
  <text>
    <status value="generated"/>
    <div xmlns="http://www.w3.org/1999/xhtml">A human-readable rendering of the Oral Health Claim</div>
  </text>
  
  <contained>
    <Organization>
      <id value="org-insurer"/>
      <identifier>
        <system value="http://www.bindb.com/bin"/>
        <value value="123456"/>
      </identifier>
    </Organization>
  </contained>

  <contained>
    <Organization>
      <id value="org-org"/>
      <identifier>
        <system value="http://www.jurisdiction.com/oralhealthoffices"/>
        <value value="3456"/>
      </identifier>
    </Organization>
  </contained>

  <contained>
    <Practitioner>
      <id value="provider-1"/>
      <identifier>
        <system value="http://www.jurisdiction.com/oralhealthproviders"/>
        <value value="123456789"/>
      </identifier>
    </Practitioner>
  </contained>
 
  <contained>
    <Patient>
      <id value="patient-1"/>
      <name>
        <use value="official"/>
        <family value="Donald"/>
        <given value="Duck"/>
      </name>
      <gender value="male"/>
      <birthDate value="1986-05-17"/>
      <address>
        <use value="home"/>
        <line value="1234 Main Street"/>
        <city value="Vancouver"/>
        <postalCode value="V2H1Y3"/>
        <country value="CAD"/>
      </address>
    </Patient>
  </contained>
  
  <contained>
    <Coverage>
      <id value="coverage-1"/>
    
      <identifier>
        <system value="http://benefitsinc.com/certificate"/>
        <value value="12345"/>
      </identifier>

      <status value="active"/>

      <type>
     <coding>
        <system value="http://hl7.org/fhir/v3/ActCode"/>
        <code value="EHCPOL"/>
       </coding>
    </type>
    
      <subscriber>
        <reference value="#patient-1"/>
      </subscriber>
 
      <beneficiary>
        <reference value="#patient-1"/>
      </beneficiary>
 
      <relationship>
     <coding>
        <code value="self"/>
       </coding>
    </relationship>

      <payor>
      <identifier>
          <system value="http://www.bindb.com/bin"/>
          <value value="123456"/>
      </identifier>
      </payor>
    
    <group>
      <plan value="CBI35"/>
        <planDisplay value="Corporate Baker's Inc. Plan#35"/>
        <subPlan value="123"/>
        <subPlanDisplay value="Trainee Part-time Benefits"/>
    </group> 
        
      <dependent value="1"/>
      <sequence value="1"/>
    </Coverage>
  </contained>
  
  <identifier>
    <system value="http://happyvalley.com/claim"/>
    <value value="12347"/>
  </identifier>
  
  <status value="active"/>
  
  <type>
   <coding>
    <system value="http://hl7.org/fhir/ex-claimtype"/>
    <code value="oral"/>
   </coding>
  </type>

  <use value="complete"/>
  
  <patient>
    <reference value="#patient-1"/>
  </patient>

  <created value="2014-08-16"/>
  
  <insurer>
    <reference value="#org-insurer"/>
  </insurer>
  
  <organization>
    <reference value="#org-org"/>
  </organization>  
  
  <priority>
   <coding>
    <code value="normal"/>
   </coding>
  </priority>
  
  <payee>
    <type>
   <coding>
      <code value="provider"/>
     </coding>
  </type>
  </payee>

   <careTeam>
    <sequence value="1"/>
    <provider>
      <reference value="#provider-1"/>
    </provider>
   </careTeam>
  
  <diagnosis>
    <sequence value="1"/>
    <diagnosisCodeableConcept>
   <coding>
      <code value="123456"/>
     </coding>
  </diagnosisCodeableConcept>
  </diagnosis>
  
  <insurance>
    <sequence value="1"/>
    <focal value="true"/>
    <coverage>
      <reference value="#coverage-1"/>
    </coverage>
  </insurance>
  
  <item>
    <sequence value="1"/>
    <careTeamLinkId value="1"/>
    <service>
   <coding>
      <code value="1200"/>
     </coding>
  </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>