This page is part of the FHIR Specification (v3.0.2: STU 3). 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
Financial Management Work Group | Maturity Level: N/A | Ballot Status: Informative | Compartments: Encounter, Patient, Practitioner, RelatedPerson |
Average dental Claim with Information (Missing Teeth and Student) (id = "100151")
<Claim xmlns="http://hl7.org/fhir"> <id value="100151"/> <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="12346"/> </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="Organization/2"/> </insurer> <organization> <reference value="Organization/1"/> </organization> <priority> <coding> <code value="normal"/> </coding> </priority> <payee> <type> <coding> <code value="provider"/> </coding> </type> </payee> <careTeam> <sequence value="1"/> <provider> <reference value="Practitioner/example"/> </provider> </careTeam> <information> <sequence value="1"/> <category> <coding> <system value="http://hl7.org/fhir/claiminformationcategory"/> <code value="missingtooth"/> </coding> </category> <code> <coding> <system value="http://hl7.org/fhir/ex-tooth"/> <code value="15"/> </coding> </code> <timingDate value="2012-04-07"/> <reason> <coding> <system value="http://hl7.org/fhir/missingtoothreason"/> <code value="e"/> <!-- Extraction --> </coding> </reason> </information> <information> <sequence value="2"/> <category> <coding> <system value="http://hl7.org/fhir/claiminformationcategory"/> <code value="exception"/> </coding> </category> <code> <coding> <system value="http://hl7.org/fhir/claim-exception"/> <code value="student"/> </coding> </code> <valueString value="Happy Valley Community College"/> </information> <diagnosis> <sequence value="1"/> <diagnosisCodeableConcept> <coding> <code value="123456"/> </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://example.org/fhir/oralservicecodes"/> <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> <item> <sequence value="2"/> <careTeamLinkId value="1"/> <service> <coding> <system value="http://example.org/fhir/oralservicecodes"/> <code value="21211"/> </coding> </service> <servicedDate value="2014-08-16"/> <unitPrice> <value value="105.00"/> <system value="urn:iso:std:iso:4217"/> <code value="USD"/> </unitPrice> <net> <value value="105.00"/> <system value="urn:iso:std:iso:4217"/> <code 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"/> <careTeamLinkId value="1"/> <service> <coding> <system value="http://example.org/fhir/oralservicecodes"/> <code value="27211"/> </coding> </service> <servicedDate value="2014-08-16"/> <unitPrice> <value value="1100.00"/> <system value="urn:iso:std:iso:4217"/> <code value="USD"/> </unitPrice> <net> <value value="1100.00"/> <system value="urn:iso:std:iso:4217"/> <code value="USD"/> </net> <bodySite> <coding> <system value="http://fdi.org/fhir/oraltoothcodes"/> <code value="36"/> </coding> </bodySite> <detail> <sequence value="1"/> <service> <coding> <system value="http://example.org/fhir/oralservicecodes"/> <code value="27211"/> </coding> </service> <unitPrice> <value value="1000.00"/> <system value="urn:iso:std:iso:4217"/> <code value="USD"/> </unitPrice> <factor value="0.75"/> <!-- Student discount --> <net> <value value="750.00"/> <system value="urn:iso:std:iso:4217"/> <code value="USD"/> </net> </detail> <detail> <sequence value="2"/> <service> <coding> <system value="http://example.org/fhir/oralservicecodes"/> <code value="lab"/> </coding> </service> <unitPrice> <value value="350.00"/> <system value="urn:iso:std:iso:4217"/> <code value="USD"/> </unitPrice> <net> <value value="350.00"/> <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.