R6 Ballot (2nd Draft)

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Example Claim/100153 (XML)

Financial Management Work GroupMaturity Level: N/AStandards Status: InformativeCompartments: Device, 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"/>   -->
        <code value="K07.3"/> 
      </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"/> 
    <productOrService> 
      <coding> 
        <system value="http://example.org/fhir/oralservicecodes"/> 
        <code value="ORTHPLAN"/> 
      </coding> 
    </productOrService> 
    <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   -->
      <productOrService> 
        <coding> 
          <system value="http://example.org/fhir/oralservicecodes"/> 
          <code value="ORTHOEXAM"/> 
        </coding> 
      </productOrService> 
      <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   -->
      <productOrService> 
        <coding> 
          <system value="http://example.org/fhir/oralservicecodes"/> 
          <code value="ORTHODIAG"/> 
        </coding> 
      </productOrService> 
      <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   -->
      <productOrService> 
        <coding> 
          <system value="http://example.org/fhir/oralservicecodes"/> 
          <code value="ORTHOINITIAL"/> 
        </coding> 
      </productOrService> 
      <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   -->
      <productOrService> 
        <coding> 
          <system value="http://example.org/fhir/oralservicecodes"/> 
          <code value="ORTHOMONTHS"/> 
        </coding> 
      </productOrService> 
      <quantity> 
        <value value="24"/> 
      </quantity> 
    </detail> 
    <detail> 
      <sequence value="5"/> 
      <!--   Periodic Payments   -->
      <productOrService> 
        <coding> 
          <system value="http://example.org/fhir/oralservicecodes"/> 
          <code value="ORTHOPERIODIC"/> 
        </coding> 
      </productOrService> 
      <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"/> 
    <productOrService> 
      <coding> 
        <system value="http://example.org/fhir/oralservicecodes"/> 
        <code value="21211"/> 
      </coding> 
    </productOrService> 
    <servicedDate value="2014-08-16"/> 
    <unitPrice> 
      <value value="105.00"/> 
      <currency value="USD"/> 
    </unitPrice> 
    <net> 
      <value value="105.00"/> 
      <currency value="USD"/> 
    </net> 
    <bodySite> 
      <site> 
        <concept> 
          <coding> 
            <system value="http://fdi.org/fhir/oraltoothcodes"/> 
            <code value="21"/> 
          </coding> 
        </concept> 
      </site> 
      <subSite> 
        <coding> 
          <system value="http://fdi.org/fhir/oralsurfacecodes"/> 
          <code value="L"/> 
        </coding> 
      </subSite> 
    </bodySite> 
  </item> 
  <item> 
    <sequence value="3"/> 
    <careTeamSequence value="1"/> 
    <productOrService> 
      <coding> 
        <system value="http://example.org/fhir/oralservicecodes"/> 
        <code value="27211"/> 
      </coding> 
    </productOrService> 
    <servicedDate value="2014-08-16"/> 
    <unitPrice> 
      <value value="1100.00"/> 
      <currency value="USD"/> 
    </unitPrice> 
    <net> 
      <value value="1100.00"/> 
      <currency value="USD"/> 
    </net> 
    <bodySite> 
      <site> 
        <concept> 
          <coding> 
            <system value="http://fdi.org/fhir/oraltoothcodes"/> 
            <code value="36"/> 
          </coding> 
        </concept> 
      </site> 
    </bodySite> 
    <detail> 
      <sequence value="1"/> 
      <productOrService> 
        <coding> 
          <system value="http://example.org/fhir/oralservicecodes"/> 
          <code value="27211"/> 
        </coding> 
      </productOrService> 
      <unitPrice> 
        <value value="750.00"/> 
        <currency value="USD"/> 
      </unitPrice> 
      <net> 
        <value value="750.00"/> 
        <currency value="USD"/> 
      </net> 
    </detail> 
    <detail> 
      <sequence value="2"/> 
      <productOrService> 
        <coding> 
          <system value="http://example.org/fhir/oralservicecodes"/> 
          <code value="lab"/> 
        </coding> 
      </productOrService> 
      <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.