Claim-example-vision-glasses.xml

Glasses Claim (id = "660151")

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

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

  <use value="claim"/> 

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

  <created value="2014-08-16"/> 

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

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

  <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"/> 
    <careTeamSequence value="1"/> 
    <productOrService> 
      <coding> 
        <system value="http://example.org/fhir/CodeSystem/ex-visionservice"/> 
        <code value="glasses"/> 
      </coding> 
    </productOrService> 
    <servicedDate value="2014-08-16"/> 
    <unitPrice> 
      <value value="214.00"/> 
      <currency value="USD"/>  
    </unitPrice>  
    <net> 
      <value value="214.00"/> 
      <currency value="USD"/>  
    </net>  
    <detail> 
      <sequence value="1"/> 
      <productOrService> 
        <coding> 
          <system value="http://example.org/fhir/CodeSystem/ex-visionservice"/> 
          <code value="frame"/> 
        </coding> 
      </productOrService> 
      <unitPrice> 
        <value value="100.00"/> 
        <currency value="USD"/>  
      </unitPrice>  
      <net> 
        <value value="100.00"/> 
        <currency value="USD"/>  
      </net>  
    </detail> 
    <detail> 
      <sequence value="2"/> 
      <productOrService> 
        <coding> 
          <system value="http://example.org/fhir/CodeSystem/ex-visionservice"/> 
          <code value="lens"/> 
        </coding> 
      </productOrService> 
      <quantity> 
        <value value="2"/> 
      </quantity> 
      <unitPrice> 
        <value value="50.00"/> 
        <currency value="USD"/>  
      </unitPrice>  
      <net> 
        <value value="100.00"/> 
        <currency value="USD"/>  
      </net>  
    </detail> 
    <detail> 
      <sequence value="3"/> 
      <productOrService> 
        <coding> 
          <system value="http://example.org/fhir/CodeSystem/ex-visionservice"/> 
          <code value="fst"/> 
        </coding> 
      </productOrService> 
      <unitPrice> 
        <value value="200.00"/> 
        <currency value="USD"/>  
      </unitPrice>  
      <factor value="0.07"/> 
      <net> 
        <value value="14.00"/> 
        <currency value="USD"/>  
      </net>  
    </detail> 
  </item> 

</Claim>