Claim-example.xml

Simple dental Claim (id = "100150")

<Claim xmlns="http://hl7.org/fhir">
  <id value="100150"/> 

  <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="12345"/> 
  </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> 
 
  <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> 
     <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> 

</Claim>