Claim-example-institutional.xml

Simple Institutional Service Claim (id = "960150")

<?xml version="1.0" encoding="UTF-8"?>

<Claim xmlns="http://hl7.org/fhir">
  <id value="960150"/> 

  <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://happyhospital.com/claim"/> 
    <value value="9612345"/> 
  </identifier> 

  <status value="active"/> 

  <type> 
    <coding> 
      <system value="http://terminology.hl7.org/CodeSystem/claim-type"/> 
      <code value="institutional"/> 
    </coding> 
  </type> 

  <subType> 
    <coding> 
      <system value="http://terminology.hl7.org/CodeSystem/ex-claimsubtype"/> 
      <code value="emergency"/> 
    </coding> 
  </subType>  

  <use value="claim"/> 

  <patient> 
    <reference value="Patient/1"/> 
  </patient> 

  <created value="2014-08-16"/> 

  <enterer> 
    <identifier> 
      <system value="http://jurisdiction.org/facilities/HOSP1234/users"/> 
      <value value="UC1234"/> 
    </identifier> 
  </enterer> 

  <insurer> 
    <reference value="Organization/2"/> 
  </insurer> 

  <provider> 
    <reference value="Organization/1"/> 
  </provider> 

  <priority> 
    <coding> 
      <code value="normal"/> 
    </coding> 
  </priority> 

  <payee> 
    <type> 
      <coding> 
        <code value="provider"/> 
      </coding> 
    </type> 
  </payee> 

  <facility> 
    <identifier> 
      <system value="http://jurisdiction.org/facilities"/> 
      <value value="HOSP1234"/> 
    </identifier> 
  </facility> 

  <careTeam> 
    <sequence value="1"/> 
    <provider> 
      <reference value="Practitioner/example"/> 
    </provider> 
  </careTeam> 

  <diagnosis> 
    <sequence value="1"/> 
    <diagnosisCodeableConcept> 
      <coding> 
        <code value="654456"/> 
      </coding> 
    </diagnosisCodeableConcept> 
  </diagnosis> 

  <procedure> 
    <sequence value="1"/> 
    <type> 
      <coding> 
        <code value="primary"/> 
      </coding> 
    </type>   
    <date value="2014-08-16"/> 
    <procedureCodeableConcept> 
      <coding> 
        <code value="SDI9901"/> 
      </coding> 
      <text value="Subcutaneous diagnostic implant"/> 
    </procedureCodeableConcept> 
    <udi> 
      <reference value="Device/example"/> 
    </udi> 
  </procedure> 

  <insurance> 
    <sequence value="1"/> 
    <focal value="true"/> 
    <coverage> 
      <reference value="Coverage/9876B1"/> 
    </coverage> 
  </insurance> 

  <item> 
    <sequence value="1"/> 
    <careTeamSequence value="1"/> 
    <productOrService> 
      <coding> 
        <system value="http://hl7.org/fhir/ex-serviceproduct"/> 
        <code value="exam"/>  
      </coding> 
    </productOrService> 
    <servicedDate value="2014-08-16"/> 
    <unitPrice> 
      <value value="125.00"/> 
      <currency value="USD"/>  
    </unitPrice>  
    <net> 
      <value value="125.00"/> 
      <currency value="USD"/>  
    </net>  
    <encounter> 
      <reference value="Encounter/example"/> 
    </encounter> 
  </item> 

  <total> 
    <value value="125.00"/> 
    <currency value="USD"/>   
  </total> 
</Claim>