R4 Ballot #2 (Mixed Normative/Trial use)

This page is part of the FHIR Specification (v3.5.0: R4 Ballot #2). 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-oral-orthoplan.xml

Financial Management Work GroupMaturity Level: N/ABallot Status: InformativeCompartments: Encounter, Patient, Practitioner, RelatedPerson

Raw XML (canonical form + also see XML Format Specification)

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PreAuthorization with Orthodontic Treatment Plan (id = "100153")

<?xml version="1.0" encoding="UTF-8"?>

<Claim xmlns="http://hl7.org/fhir">
  <id value="100153"/> 

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

  <identifier> 
    <system value="http://happyvalley.com/claim"/> 
    <value value="12355"/> 
  </identifier> 

  <status value="active"/> 

  <type> 
    <coding> 
      <system value="http://terminology.hl7.org/CodeSystem/claim-type"/> 
      <code value="oral"/> 
    </coding> 
  </type> 

  <use value="preauthorization"/> 

  <patient> 
    <reference value="Patient/1"/> 
  </patient> 

  <created value="2015-03-16"/> 

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

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

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

  <fundsReserve> 
    <coding> 
      <code value="provider"/> 
    </coding> 
  </fundsReserve> 

  <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> 
        <system value="http://hl7.org/fhir/sid/icd-10"/> 
        <code value="123457"/> 
      </coding> 
    </diagnosisCodeableConcept> 
  </diagnosis> 

  <insurance> 
    <sequence value="1"/> 
    <focal value="true"/> 
    <coverage> 
      <reference value="Coverage/9876B1"/> 
    </coverage> 
  </insurance> 

  <item> 
    <sequence value="1"/> 
    <careTeamSequence value="1"/> 
    <diagnosisSequence value="1"/> 
    <billcode> 
      <coding> 
        <system value="http://example.org/fhir/oralservicecodes"/> 
        <code value="ORTHPLAN"/> 
      </coding> 
    </billcode> 
    <servicedDate value="2015-05-16"/>   <!--   Start Date   -->
    <unitPrice> 
      <value value="9000.00"/> 
      <currency value="USD"/>  
    </unitPrice>  
    <net> 
      <value value="9000.00"/> 
      <currency value="USD"/>  
    </net>  
    <detail> 
      <sequence value="1"/>  <!--   Exam Fee   -->
      <billcode> 
        <coding> 
          <system value="http://example.org/fhir/oralservicecodes"/> 
          <code value="ORTHOEXAM"/> 
        </coding> 
      </billcode> 
      <unitPrice> 
        <value value="1000.00"/> 
        <currency value="USD"/>  
      </unitPrice>  
      <net> 
        <value value="1000.00"/> 
        <currency value="USD"/>  
      </net>  
    </detail> 
    <detail> 
      <sequence value="2"/>  <!--   Diagnostic Fee   -->
      <billcode> 
        <coding> 
          <system value="http://example.org/fhir/oralservicecodes"/> 
          <code value="ORTHODIAG"/> 
        </coding> 
      </billcode> 
      <unitPrice> 
        <value value="1500.00"/> 
        <currency value="USD"/>  
      </unitPrice>  
      <net> 
        <value value="1500.00"/> 
        <currency value="USD"/>  
      </net>  
    </detail> 
    <detail> 
      <sequence value="3"/>  <!--   Initial Payment   -->
      <billcode> 
        <coding> 
          <system value="http://example.org/fhir/oralservicecodes"/> 
          <code value="ORTHOINITIAL"/> 
        </coding> 
      </billcode> 
      <unitPrice> 
        <value value="500.00"/> 
        <currency value="USD"/>  
      </unitPrice>  
      <net> 
        <value value="500.00"/> 
        <currency value="USD"/>  
      </net>  
    </detail> 
    <detail> 
      <sequence value="4"/>  <!--   Duration in Months   -->
      <billcode> 
        <coding> 
          <system value="http://example.org/fhir/oralservicecodes"/> 
          <code value="ORTHOMONTHS"/> 
        </coding> 
      </billcode> 
      <quantity> 
        <value value="24"/> 
      </quantity>   
    </detail> 
    <detail> 
      <sequence value="5"/>  <!--   Periodic Payments   -->
      <billcode> 
        <coding> 
          <system value="http://example.org/fhir/oralservicecodes"/> 
          <code value="ORTHOPERIODIC"/> 
        </coding> 
      </billcode> 
      <quantity> 
        <value value="24"/> 
      </quantity>   
      <unitPrice> 
        <value value="250.00"/> 
        <currency value="USD"/>  
      </unitPrice>  
      <net> 
        <value value="250.00"/> 
        <currency value="USD"/>  
      </net>  
    </detail> 
  </item> 

  <item> 
    <sequence value="2"/> 
    <careTeamSequence value="1"/> 
    <billcode> 
      <coding> 
        <system value="http://example.org/fhir/oralservicecodes"/> 
        <code value="21211"/> 
      </coding> 
    </billcode> 
    <servicedDate value="2014-08-16"/> 
    <unitPrice> 
      <value value="105.00"/> 
      <currency value="USD"/>  
    </unitPrice>  
    <net> 
      <value value="105.00"/> 
      <currency value="USD"/>  
    </net>  
    <bodySite> 
      <coding> 
        <system value="http://fdi.org/fhir/oraltoothcodes"/> 
        <code value="21"/> 
      </coding> 
    </bodySite> 
    <subSite> 
      <coding> 
        <system value="http://fdi.org/fhir/oralsurfacecodes"/> 
        <code value="L"/> 
      </coding> 
    </subSite> 
  </item> 

  <item> 
    <sequence value="3"/> 
    <careTeamSequence value="1"/> 
    <billcode> 
      <coding> 
        <system value="http://example.org/fhir/oralservicecodes"/> 
        <code value="27211"/> 
      </coding> 
    </billcode> 
    <servicedDate value="2014-08-16"/> 
    <unitPrice> 
      <value value="1100.00"/> 
      <currency value="USD"/>  
    </unitPrice>  
    <net> 
      <value value="1100.00"/> 
      <currency value="USD"/>  
    </net>  
    <bodySite> 
      <coding> 
        <system value="http://fdi.org/fhir/oraltoothcodes"/> 
        <code value="36"/> 
      </coding> 
    </bodySite> 
    <detail> 
      <sequence value="1"/> 
      <billcode> 
        <coding> 
          <system value="http://example.org/fhir/oralservicecodes"/> 
          <code value="27211"/> 
        </coding> 
      </billcode> 
      <unitPrice> 
        <value value="750.00"/> 
        <currency value="USD"/>  
      </unitPrice>  
      <net> 
        <value value="750.00"/> 
        <currency value="USD"/>  
      </net>  
    </detail> 
    <detail> 
      <sequence value="2"/> 
      <billcode> 
        <coding> 
          <system value="http://example.org/fhir/oralservicecodes"/> 
          <code value="lab"/> 
        </coding> 
      </billcode> 
      <unitPrice> 
        <value value="350.00"/> 
        <currency value="USD"/>  
      </unitPrice>  
      <net> 
        <value value="350.00"/> 
        <currency 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.