This page is part of the FHIR Specification (v3.2.0: R4 Ballot 1). 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
Claim-example-vision-glasses-3tier.xml

Financial Management Work Group
Maturity Level: N/A
Ballot Status: Informative
Compartments: Encounter, Patient, Practitioner, RelatedPerson
Raw XML (canonical form)
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Glasses Claim, 3 Tier, Secondary Coverage (id = "660152")
<Claim xmlns="http://hl7.org/fhir">
  <id value="660152"/> 

  <text> 
    <status value="generated"/> 
    <div xmlns="http://www.w3.org/1999/xhtml">A human-readable rendering of the Vision Claim for Glasses</div> 
  </text> 

  <contained> 
    <ClaimResponse> 
      <id value="claimresponse-1"/> 

      <identifier> 
        <system value="http://thebenefircompany.com/claimresponse"/> 
        <value value="CR6532875367"/> 
      </identifier> 

      <!--   rest of the resource ommitted for brevity   -->

    </ClaimResponse> 
  </contained> 

  <contained> 
    <Device> 
      <id value="device-frame"/> 
      <!--   rest of the resource ommitted for brevity   -->
    </Device> 
  </contained> 

  <contained> 
    <Device> 
      <id value="device-lens"/> 
      <!--   rest of the resource ommitted for brevity   -->
    </Device> 
  </contained> 


  <identifier> 
    <system value="http://happysight.com/claim"/> 
    <value value="6612347"/> 
  </identifier> 

  <status value="active"/> 

  <type> 
    <coding> 
      <system value="http://hl7.org/fhir/ex-claimtype"/> 
      <code value="vision"/> 
    </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> 

  <prescription> 
    <reference value="http://www.optdocs.com/prescription/12345"/> 
  </prescription>    

  <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="654321"/> 
      </coding> 
    </diagnosisCodeableConcept> 
  </diagnosis> 

  <insurance>  <!--   Patient's own coverage - primary   -->
    <sequence value="1"/> 
    <focal value="false"/> 
    <coverage> 
      <reference value="Coverage/9876B1"/> 
    </coverage> 
    <preAuthRef value="PR7652387237"/> 
    <claimResponse> 
      <reference value="#claimresponse-1"/> 
    </claimResponse> 
  </insurance> 

  <insurance>  <!--   Spouses's own coverage - secondary   -->
    <sequence value="2"/> 
    <focal value="true"/> 
    <coverage> 
      <reference value="Coverage/9876B1"/> 
    </coverage> 
    <preAuthRef value="AB543GTD7567"/> 
  </insurance> 

  <item> 
    <sequence value="1"/> 
    <careTeamSequence value="1"/> 
    <revenue> 
      <coding> 
        <system value="http://hl7.org/fhir/ex-revenue-center"/> 
        <code value="0010"/> 
        <display value="Vision Clinic"/> 
      </coding> 
    </revenue> 
    <category> 
      <coding> 
        <system value="http://hl7.org/fhir/benefit-subcategory"/> 
        <code value="F6"/> 
        <display value="Vision Coverage"/> 
      </coding> 
    </category> 
    <service> 
      <coding> 
        <system value="http://hl7.org/fhir/ex-visionservice"/> 
        <code value="glasses"/> 
      </coding> 
    </service> 
    <modifier> 
      <coding> 
        <system value="http://hl7.org/fhir/modifiers"/> 
        <code value="rooh"/> 
      </coding> 
    </modifier> 
    <programCode> 
      <coding> 
        <system value="http://hl7.org/fhir/ex-programcode"/> 
        <code value="none"/> 
      </coding> 
    </programCode>   
    <servicedDate value="2014-08-16"/> 
    <unitPrice> 
      <value value="235.40"/> 
      <system value="urn:iso:std:iso:4217"/> 
      <code value="USD"/>  
    </unitPrice>  
    <net> 
      <value value="235.40"/> 
      <system value="urn:iso:std:iso:4217"/> 
      <code value="USD"/>  
    </net>  

    <detail> 
      <sequence value="1"/> 
      <revenue> 
        <coding> 
          <system value="http://hl7.org/fhir/ex-revenue-center"/> 
          <code value="0010"/> 
          <display value="Vision Clinic"/> 
        </coding> 
      </revenue> 
      <category> 
        <coding> 
          <system value="http://hl7.org/fhir/benefit-subcategory"/> 
          <code value="F6"/> 
          <display value="Vision Coverage"/> 
        </coding> 
      </category> 
      <service> 
        <coding> 
          <system value="http://hl7.org/fhir/ex-visionservice"/> 
          <code value="frame"/> 
        </coding> 
      </service> 
      <modifier> 
        <coding> 
          <system value="http://hl7.org/fhir/modifiers"/> 
          <code value="rooh"/> 
        </coding> 
      </modifier> 
      <unitPrice> 
        <value value="100.00"/> 
        <system value="urn:iso:std:iso:4217"/> 
        <code value="USD"/>  
      </unitPrice>  
      <factor value="1.1"/>  <!--   10% surchage for out of hours work   -->
      <net> 
        <value value="110.00"/> 
        <system value="urn:iso:std:iso:4217"/> 
        <code value="USD"/>  
      </net>  
      <udi> 
        <reference value="#device-frame"/> 
      </udi> 
    </detail> 

    <detail> 
      <sequence value="2"/> 
      <revenue> 
        <coding> 
          <system value="http://hl7.org/fhir/ex-revenue-center"/> 
          <code value="0010"/> 
          <display value="Vision Clinic"/> 
        </coding> 
      </revenue> 
      <category> 
        <coding> 
          <system value="http://hl7.org/fhir/benefit-subcategory"/> 
          <code value="F6"/> 
          <display value="Vision Coverage"/> 
        </coding> 
      </category> 
      <service> 
        <coding> 
          <system value="http://hl7.org/fhir/ex-visionservice"/> 
          <code value="lens"/> 
        </coding> 
      </service> 
      <programCode> 
        <coding> 
          <system value="http://hl7.org/fhir/ex-programcode"/> 
          <code value="none"/> 
        </coding> 
      </programCode>   
      <quantity> 
        <value value="2"/> 
      </quantity> 
      <unitPrice> 
        <value value="55.00"/> 
        <system value="urn:iso:std:iso:4217"/> 
        <code value="USD"/>  
      </unitPrice>  
      <net> 
        <value value="110.00"/> 
        <system value="urn:iso:std:iso:4217"/> 
        <code value="USD"/>  
      </net>  

      <subDetail> 
        <sequence value="1"/> 
        <revenue> 
          <coding> 
            <system value="http://hl7.org/fhir/ex-revenue-center"/> 
            <code value="0010"/> 
            <display value="Vision Clinic"/> 
          </coding> 
        </revenue> 
        <category> 
          <coding> 
            <system value="http://hl7.org/fhir/benefit-subcategory"/> 
            <code value="F6"/> 
            <display value="Vision Coverage"/> 
          </coding> 
        </category> 
        <service> 
          <coding> 
            <system value="http://hl7.org/fhir/ex-visionservice"/> 
            <code value="lens"/> 
          </coding> 
        </service> 
        <modifier> 
          <coding> 
            <system value="http://hl7.org/fhir/modifiers"/> 
            <code value="rooh"/> 
          </coding> 
        </modifier> 
        <programCode> 
          <coding> 
            <system value="http://hl7.org/fhir/ex-programcode"/> 
            <code value="none"/> 
          </coding> 
        </programCode>   
        <quantity> 
          <value value="2"/> 
        </quantity> 
        <unitPrice> 
          <value value="30.00"/> 
          <system value="urn:iso:std:iso:4217"/> 
          <code value="USD"/>  
        </unitPrice>  
        <factor value="1.1"/>  <!--   10% surchage for out of hours work   -->
        <net> 
          <value value="66.00"/> 
          <system value="urn:iso:std:iso:4217"/> 
          <code value="USD"/>  
        </net>  
        <udi> 
          <reference value="#device-lens"/> 
        </udi> 
      </subDetail> 

      <subDetail> 
        <sequence value="2"/> 
        <revenue> 
          <coding> 
            <system value="http://hl7.org/fhir/ex-revenue-center"/> 
            <code value="0010"/> 
            <display value="Vision Clinic"/> 
          </coding> 
        </revenue> 
        <category> 
          <coding> 
            <system value="http://hl7.org/fhir/benefit-subcategory"/> 
            <code value="F6"/> 
            <display value="Vision Coverage"/> 
          </coding> 
        </category> 
        <service> 
          <coding> 
            <system value="http://hl7.org/fhir/ex-visionservice"/> 
            <code value="hardening"/> 
          </coding> 
        </service> 
        <modifier> 
          <coding> 
            <system value="http://hl7.org/fhir/modifiers"/> 
            <code value="rooh"/> 
          </coding> 
        </modifier> 
        <quantity> 
          <value value="2"/> 
        </quantity> 
        <unitPrice> 
          <value value="15.00"/> 
          <system value="urn:iso:std:iso:4217"/> 
          <code value="USD"/>  
        </unitPrice>  
        <factor value="1.1"/>  <!--   10% surchage for out of hours work   -->
        <net> 
          <value value="33.00"/> 
          <system value="urn:iso:std:iso:4217"/> 
          <code value="USD"/>  
        </net>  
      </subDetail> 

      <subDetail> 
        <sequence value="3"/> 
        <revenue> 
          <coding> 
            <system value="http://hl7.org/fhir/ex-revenue-center"/> 
            <code value="0010"/> 
            <display value="Vision Clinic"/> 
          </coding> 
        </revenue> 
        <category> 
          <coding> 
            <system value="http://hl7.org/fhir/benefit-subcategory"/> 
            <code value="F6"/> 
            <display value="Vision Coverage"/> 
          </coding> 
        </category> 
        <service> 
          <coding> 
            <system value="http://hl7.org/fhir/ex-visionservice"/> 
            <code value="UV coating"/> 
          </coding> 
        </service> 
        <modifier> 
          <coding> 
            <system value="http://hl7.org/fhir/modifiers"/> 
            <code value="rooh"/> 
          </coding> 
        </modifier> 
        <quantity> 
          <value value="2"/> 
        </quantity> 
        <unitPrice> 
          <value value="5.00"/> 
          <system value="urn:iso:std:iso:4217"/> 
          <code value="USD"/>  
        </unitPrice>  
        <factor value="1.1"/>  <!--   10% surchage for out of hours work   -->
        <net> 
          <value value="11.00"/> 
          <system value="urn:iso:std:iso:4217"/> 
          <code value="USD"/>  
        </net>  
      </subDetail> 
    </detail> 

    <detail> 
      <sequence value="3"/> 
      <revenue> 
        <coding> 
          <system value="http://hl7.org/fhir/ex-revenue-center"/> 
          <code value="0010"/> 
          <display value="Vision Clinic"/> 
        </coding> 
      </revenue> 
      <category> 
        <coding> 
          <system value="http://hl7.org/fhir/benefit-subcategory"/> 
          <code value="F6"/> 
          <display value="Vision Coverage"/> 
        </coding> 
      </category> 
      <service> 
        <coding> 
          <system value="http://hl7.org/fhir/ex-visionservice"/> 
          <code value="fst"/> 
        </coding> 
      </service> 
      <unitPrice> 
        <value value="220.00"/> 
        <system value="urn:iso:std:iso:4217"/> 
        <code value="USD"/>  
      </unitPrice>  
      <factor value="0.07"/> 
      <net> 
        <value value="15.40"/> 
        <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.