STU3 Candidate

This page is part of the FHIR Specification (v1.8.0: STU 3 Draft). 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

Claim-example-vision-glasses.xml

Raw XML (canonical form)

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>
   <coding>
    <system value="http://hl7.org/fhir/ex-claimtype"/>
    <code value="vision"/>
   </coding>
  </type>
  
 <use value="complete"/>

 <patient>
   <reference value="Patient/1"/>
 </patient>
 
  <created value="2014-08-16"/>

 <insurer>
  <reference value="Organization/2"/>
 </insurer>

 <organization>
    <reference value="Organization/1"/>
 </organization>

 <priority>
  <coding>
    <code value="normal"/>
  </coding>
 </priority>

 <prescription>
   <reference value="http://www.optdocs.com/prescription/12345"/>
 </prescription>   
 
 <payee>
   <type>
    <coding>
     <code value="provider"/>
    </coding>
   </type>
 </payee>

   <careTeam>
     <sequence value="1"/>
     <provider>
       <reference value="Practitioner/example"/>
     </provider>
   </careTeam>
 
  <diagnosis>
    <sequence value="1"/>
  <diagnosisCodeableConcept>
   <coding>
    <code value="654321"/>
     </coding>
  </diagnosisCodeableConcept>
  </diagnosis>
 
 <insurance>
   <sequence value="1"/>
   <focal value="true"/>
   <coverage>
     <reference value="Coverage/9876B1"/>
   </coverage>
 </insurance>
  
 <item>
   <sequence value="1"/>
   <careTeamLinkId value="1"/>
   <service>
    <coding>
     <system value="http://hl7.org/fhir/ex-visionservice"/>
     <code value="glasses"/>
    </coding>
   </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"/>
     <service>
    <coding>
       <system value="http://hl7.org/fhir/ex-visionservice"/>
       <code value="frame"/>
      </coding>
   </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"/>
     <service>
    <coding>
       <system value="http://hl7.org/fhir/ex-visionservice"/>
       <code value="lens"/>
      </coding>
   </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"/>
     <service>
    <coding>
       <system value="http://hl7.org/fhir/ex-visionservice"/>
       <code value="fst"/>
      </coding>
   </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.