FHIR Release 3 (STU)

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

Claim-example-oral-average.xml

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

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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.