This page is part of the Da Vinci Clinical Documentation Exchange (v0.1.0: STU 1 Ballot 1) based on FHIR R4. The current version which supercedes this version is 1.1.0. For a full list of available versions, see the Directory of published versions

• Content
• XML
• JSON

XML Format: Claim-cdex-example-claim

Raw xml

<Claim xmlns="http://hl7.org/fhir">
  <id value="cdex-example-claim"/>
  <meta>
    <versionId value="2"/>
    <lastUpdated value="2019-06-06T21:52:49.000-04:00"/>
  </meta>
  <text>
    <status value="generated"/>
    <div xmlns="http://www.w3.org/1999/xhtml">A human-readable rendering of the Claim
        
        </div>
  </text>
  <identifier>
    <system value="http://happypdocs.com/claim"/>
    <value value="8612345"/>
  </identifier>
  <status value="active"/>
  <type>
    <coding>
      <system value="http://terminology.hl7.org/CodeSystem/claim-type"/>
      <code value="professional"/>
    </coding>
  </type>
  <use value="claim"/>
  <patient>
    <reference value="Patient/cdex-example-patient"/>
  </patient>
  <created value="2019-01-02"/>
  <insurer>
    <reference value="Organization/cdex-example-payer"/>
  </insurer>
  <provider>
    <reference value="Practitioner/cdex-example-practitioner"/>
  </provider>
  <priority>
    <coding>
      <code value="normal"/>
    </coding>
  </priority>
  <payee>
    <type>
      <coding>
        <code value="provider"/>
      </coding>
    </type>
  </payee>
  <careTeam>
    <sequence value="1"/>
    <provider>
      <reference value="Practitioner/cdex-example-practitioner"/>
    </provider>
  </careTeam>
  <diagnosis>
    <sequence value="1"/>
    <diagnosisCodeableConcept>
      <coding>
        <code value="654456"/>
      </coding>
    </diagnosisCodeableConcept>
  </diagnosis>
  <insurance>
    <sequence value="1"/>
    <focal value="true"/>
    <coverage>
      <reference value="Coverage/cdex-example-coverage"/>
    </coverage>
  </insurance>
  <item>
    <sequence value="1"/>
    <productOrService>
      <coding>
        <system value="http://terminology.hl7.org/CodeSystem/ex-USCLS"/>
        <code value="1101"/>
        <display value="Exam, comp, primary"/>
      </coding>
    </productOrService>
    <servicedDate value="2018-08-16"/>
    <unitPrice>
      <value value="75"/>
    </unitPrice>
    <net>
      <value value="75"/>
    </net>
  </item>
</Claim>