DSTU2 Ballot Source
This page is part of the FHIR Specification (v0.5.0: DSTU 2 Ballot 2). 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-orthoplan.xml

Raw XML (canonical form)
PreAuthorization with Orthodontic Treatment Plan (id = "100153")
Raw XML
<Claim xmlns="http://hl7.org/fhir">
  <id value="100153"/>
  <text>
    <status value="generated"/>
    <div xmlns="http://www.w3.org/1999/xhtml"><!-- Snipped for brevity --></div>
  </text>
  <type value="oral"/>
  <identifier>
    <system value="http://happyvalley.com/claim"/>
    <value value="12355"/>
  </identifier>
  <created value="2015-03-16"/>
  <target>
    <reference value="Organization/2"/>
  </target>
  <organization>
    <reference value="Organization/1"/>
  </organization>
  <use value="proposed"/>
  <priority>
    <code value="normal"/>
  </priority>
  <payee>
    <type>
      <code value="provider"/>
    </type>
  </payee>
  <diagnosis>
    <sequence value="1"/>
    <diagnosis>
      <system value="http://hl7.org/fhir/icd-10"/>
      <code value="123457"/>
    </diagnosis>
  </diagnosis>
  <patient>
    <reference value="Patient/1"/>
  </patient>
  <coverage>
    <sequence value="1"/>
    <focal value="true"/>
    <coverage>
      <reference value="Coverage/9876B1"/>
    </coverage>
    <relationship>
      <code value="self"/>
    </relationship>
  </coverage>
  <item>
    <sequence value="1"/>
    <type>
      <system value="http://hl7.org/fhir/actinvoicegroupcode"/>
      <code value="group"/>
    </type>
    <provider>
      <reference value="Practitioner/1"/>
    </provider>
    <diagnosisLinkId value="1"/>
    <service>
      <system value="http://hl7.org/fhir/oralservicecodes"/>
      <code value="ORTHPLAN"/>
    </service>
    <serviceDate value="2015-05-16"/><!--    Start Date    -->
    <unitPrice>
      <value value="9000.00"/>
      <system value="urn:std:iso:4217"/>
      <code value="USD"/>
    </unitPrice>
    <net>
      <value value="9000.00"/>
      <system value="urn:std:iso:4217"/>
      <code value="USD"/>
    </net>
    <detail>
      <sequence value="1"/><!--    Exam Fee    -->
      <type>
        <system value="http://hl7.org/fhir/actinvoicegroupcode"/>
        <code value="service"/>
      </type>
      <service>
        <system value="http://hl7.org/fhir/oralservicecodes"/>
        <code value="ORTHOEXAM"/>
      </service>
      <unitPrice>
        <value value="1000.00"/>
        <system value="urn:std:iso:4217"/>
        <code value="USD"/>
      </unitPrice>
      <net>
        <value value="1000.00"/>
        <system value="urn:std:iso:4217"/>
        <code value="USD"/>
      </net>
    </detail>
    <detail>
      <sequence value="2"/><!--    Diagnostic Fee    -->
      <type>
        <system value="http://hl7.org/fhir/actinvoicegroupcode"/>
        <code value="service"/>
      </type>
      <service>
        <system value="http://hl7.org/fhir/oralservicecodes"/>
        <code value="ORTHODIAG"/>
      </service>
      <unitPrice>
        <value value="1500.00"/>
        <system value="urn:std:iso:4217"/>
        <code value="USD"/>
      </unitPrice>
      <net>
        <value value="1500.00"/>
        <system value="urn:std:iso:4217"/>
        <code value="USD"/>
      </net>
    </detail>
    <detail>
      <sequence value="3"/><!--    Initial Payment    -->
      <type>
        <system value="http://hl7.org/fhir/actinvoicegroupcode"/>
        <code value="service"/>
      </type>
      <service>
        <system value="http://hl7.org/fhir/oralservicecodes"/>
        <code value="ORTHOINITIAL"/>
      </service>
      <unitPrice>
        <value value="500.00"/>
        <system value="urn:std:iso:4217"/>
        <code value="USD"/>
      </unitPrice>
      <net>
        <value value="500.00"/>
        <system value="urn:std:iso:4217"/>
        <code value="USD"/>
      </net>
    </detail>
    <detail>
      <sequence value="4"/><!--    Duration in Months    -->
      <type>
        <system value="http://hl7.org/fhir/actinvoicegroupcode"/>
        <code value="service"/>
      </type>
      <service>
        <system value="http://hl7.org/fhir/oralservicecodes"/>
        <code value="ORTHOMONTHS"/>
      </service>
      <quantity>
        <value value="24"/>
      </quantity>
    </detail>
    <detail>
      <sequence value="5"/><!--    Periodic Payments    -->
      <type>
        <system value="http://hl7.org/fhir/actinvoicegroupcode"/>
        <code value="service"/>
      </type>
      <service>
        <system value="http://hl7.org/fhir/oralservicecodes"/>
        <code value="ORTHOPERIODIC"/>
      </service>
      <quantity>
        <value value="24"/>
      </quantity>
      <unitPrice>
        <value value="250.00"/>
        <system value="urn:std:iso:4217"/>
        <code value="USD"/>
      </unitPrice>
      <net>
        <value value="250.00"/>
        <system value="urn:std:iso:4217"/>
        <code value="USD"/>
      </net>
    </detail>
  </item>
  <item>
    <sequence value="2"/>
    <type>
      <code value="service"/>
    </type>
    <provider>
      <reference value="Practitioner/1"/>
    </provider>
    <service>
      <system value="http://hl7.org/fhir/oralservicecodes"/>
      <code value="21211"/>
    </service>
    <serviceDate value="2014-08-16"/>
    <unitPrice>
      <value value="105.00"/>
      <system value="urn:std:iso:4217"/>
      <code value="USD"/>
    </unitPrice>
    <net>
      <value value="105.00"/>
      <system value="urn:std:iso:4217"/>
      <code value="USD"/>
    </net>
    <bodySite>
      <system value="http://fdi.org/fhir/oraltoothcodes"/>
      <code value="21"/>
    </bodySite>
    <subSite>
      <system value="http://fdi.org/fhir/oralsurfacecodes"/>
      <code value="L"/>
    </subSite>
  </item>
  <item>
    <sequence value="3"/>
    <type>
      <code value="group"/>
    </type>
    <provider>
      <reference value="Practitioner/1"/>
    </provider>
    <service>
      <system value="http://hl7.org/fhir/oralservicecodes"/>
      <code value="27211"/>
    </service>
    <serviceDate value="2014-08-16"/>
    <unitPrice>
      <value value="1100.00"/>
      <system value="urn:std:iso:4217"/>
      <code value="USD"/>
    </unitPrice>
    <net>
      <value value="1100.00"/>
      <system value="urn:std:iso:4217"/>
      <code value="USD"/>
    </net>
    <bodySite>
      <system value="http://fdi.org/fhir/oraltoothcodes"/>
      <code value="36"/>
    </bodySite>
    <detail>
      <sequence value="1"/>
      <type>
        <code value="service"/>
      </type>
      <service>
        <system value="http://hl7.org/fhir/oralservicecodes"/>
        <code value="27211"/>
      </service>
      <unitPrice>
        <value value="750.00"/>
        <system value="urn:std:iso:4217"/>
        <code value="USD"/>
      </unitPrice>
      <net>
        <value value="750.00"/>
        <system value="urn:std:iso:4217"/>
        <code value="USD"/>
      </net>
    </detail>
    <detail>
      <sequence value="2"/>
      <type>
        <code value="service"/>
      </type>
      <service>
        <system value="http://hl7.org/fhir/oralservicecodes"/>
        <code value="lab"/>
      </service>
      <unitPrice>
        <value value="350.00"/>
        <system value="urn:std:iso:4217"/>
        <code value="USD"/>
      </unitPrice>
      <net>
        <value value="350.00"/>
        <system value="urn: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.