This page is part of the electronic Long-Term Services and Supports Implementation Guide (v2.0.0-ballot: STU2 Ballot 1) based on FHIR (HL7® FHIR® Standard) R4. The current version which supersedes this version is 1.0.0. For a full list of available versions, see the Directory of published versions

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: claim2 - XML Representation

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<Claim xmlns="http://hl7.org/fhir">
  <id value="claim2"/>
  <meta>
    <versionId value="1"/>
    <lastUpdated value="2020-09-03T10:16:03.512-04:00"/>
    <source value="#KZ0jzPjXDrhCiMif"/>
    <profile
             value="http://hl7.org/fhir/us/eltss/StructureDefinition/Claim-eltss"/>
  </meta>
  <text>
    <status value="generated"/>
    <div xmlns="http://www.w3.org/1999/xhtml"><p><b>Generated Narrative: Claim</b><a name="claim2"> </a></p><div style="display: inline-block; background-color: #d9e0e7; padding: 6px; margin: 4px; border: 1px solid #8da1b4; border-radius: 5px; line-height: 60%"><p style="margin-bottom: 0px">Resource Claim &quot;claim2&quot; Version &quot;1&quot; Updated &quot;2020-09-03 10:16:03-0400&quot; </p><p style="margin-bottom: 0px">Information Source: #KZ0jzPjXDrhCiMif!</p><p style="margin-bottom: 0px">Profile: <a href="StructureDefinition-Claim-eltss.html">Claim_eltss</a></p></div><p><b>status</b>: active</p><p><b>type</b>: Professional <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="http://terminology.hl7.org/5.3.0/CodeSystem-claim-type.html">Claim Type Codes</a>#professional)</span></p><p><b>use</b>: claim</p><p><b>patient</b>: <a href="Patient-patientBSJ1.html">Patient/patientBSJ1</a> &quot; SMITH-JOHNSON&quot;</p><p><b>created</b>: 2020-05-01</p><p><b>provider</b>: <a href="Organization-funding1.html">Organization/funding1</a> &quot;Texas Department of Community Health&quot;</p><p><b>priority</b>: Normal <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="http://terminology.hl7.org/5.3.0/CodeSystem-processpriority.html">Process Priority Codes</a>#normal)</span></p><h3>Insurances</h3><table class="grid"><tr><td style="display: none">-</td><td><b>Sequence</b></td><td><b>Focal</b></td><td><b>Coverage</b></td></tr><tr><td style="display: none">*</td><td>1</td><td>true</td><td><a href="Coverage-coverage1.html">Coverage/coverage1</a></td></tr></table><blockquote><p><b>item</b></p><p><b>sequence</b>: 1</p><p><b>productOrService</b>: G0108 <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="http://terminology.hl7.org/5.3.0/CodeSystem-HCPCS-all-codes.html">HCFA Procedure Codes (HCPCS)</a>#G0108)</span></p><h3>UnitPrices</h3><table class="grid"><tr><td style="display: none">-</td><td><b>Value</b></td></tr><tr><td style="display: none">*</td><td>55</td></tr></table><h3>Nets</h3><table class="grid"><tr><td style="display: none">-</td><td><b>Value</b></td></tr><tr><td style="display: none">*</td><td>660</td></tr></table></blockquote></div>
  </text>
  <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/patientBSJ1"/>
  </patient>
  <created value="2020-05-01"/>
  <provider>🔗 
    <reference value="Organization/funding1"/>
  </provider>
  <priority>
    <coding>
      <system value="http://terminology.hl7.org/CodeSystem/processpriority"/>
      <code value="normal"/>
    </coding>
  </priority>
  <insurance>
    <sequence value="1"/>
    <focal value="true"/>
    <coverage>🔗 
      <reference value="Coverage/coverage1"/>
    </coverage>
  </insurance>
  <item>
    <sequence value="1"/>
    <productOrService>
      <coding>
        <system
                value="http://terminology.hl7.org/CodeSystem/HCPCS-all-codes"/>
        <code value="G0108"/>
      </coding>
    </productOrService>
    <unitPrice>
      <value value="55"/>
    </unitPrice>
    <net>
      <value value="660"/>
    </net>
  </item>
</Claim>