Release 4B Ballot #1

This page is part of the FHIR Specification (v4.1.0: Release 4B 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-oral-bridge.xml

Financial Management Work GroupMaturity Level: N/AStandards Status: InformativeCompartments: Device, Encounter, Patient, Practitioner, RelatedPerson

Raw XML (canonical form + also see XML Format Specification)

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PreAuthorization with Bridge and Crown (id = "100156")

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

<Claim xmlns="http://hl7.org/fhir">
  <id value="100156"/> 

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

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

  <contained> 
    <ServiceRequest> 
      <id value="referral"/> 
      <status value="active"/> 
      <intent value="order"/> 
      <subject> 
        <reference value="Patient/1"/> 
      </subject> 
      <!--   rest of the resource omitted for brevity   -->
    </ServiceRequest> 
  </contained> 

  <identifier> 
    <system value="http://happyvalley.com/claim"/> 
    <value value="123466"/> 
  </identifier> 

  <status value="active"/> 

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

  <use value="claim"/> 

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

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

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

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

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

  <related> 
    <claim> 
      <reference value="Claim/100151"/> 
    </claim> 
    <relationship> 
      <coding> 
        <system value="http://terminology.hl7.org/CodeSystem/ex-relatedclaimrelationship"/> 
        <code value="associated"/> 
      </coding> 
    </relationship> 
    <reference> 
      <value value="CASE156746B"/>  <!--   case number   -->
    </reference> 
  </related> 

  <payee> 
    <type> 
      <coding> 
        <system value="http://terminology.hl7.org/CodeSystem/payeetype"/> 
        <code value="other"/> 
      </coding> 
    </type> 
    <party> 
      <reference value="RelatedPerson/peter"/> 
    </party> 
  </payee> 

  <referral> 
    <reference value="#referral"/> 
  </referral> 

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

  <supportingInfo> 
    <sequence value="1"/> 
    <category> 
      <coding> 
        <system value="http://terminology.hl7.org/CodeSystem/claiminformationcategory"/> 
        <code value="prosthesis"/> 
      </coding> 
    </category> 
    <code> 
      <coding> 
        <system value="http://hl7.org/fhir/ex-oralprostho"/> 
        <code value="2"/> 
        <display value="Maryland Bridge"/> 
      </coding> 
    </code> 
    <timingDate value="2001-04-07"/>  <!--   original placement   -->
  </supportingInfo> 

  <procedure> 
    <sequence value="1"/>    
    <date value="2014-07-04"/> 
    <procedureCodeableConcept> 
      <text value="Resection of gum to increase exposed tooth."/> 
    </procedureCodeableConcept> 
  </procedure> 

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

  <item> 
    <sequence value="1"/> 
    <careTeamSequence value="1"/> 
    <informationSequence value="1"/> 
    <productOrService> 
      <coding> 
        <system value="http://example.org/fhir/oralservicecodes"/> 
        <code value="67221"/> 
        <display value="Maryland Bridge"/> 
      </coding> 
    </productOrService> 
    <servicedDate value="2014-08-16"/> 
    <locationCodeableConcept> 
      <coding> 
        <system value="http://terminology.hl7.org/CodeSystem/ex-serviceplace"/> 
        <code value="11"/> 
      </coding> 
    </locationCodeableConcept> 
    <unitPrice> 
      <value value="1400.00"/> 
      <currency value="USD"/>  
    </unitPrice>  
    <factor value="0.75"/>  <!--   student discount   -->
    <net> 
      <value value="1050.00"/> 
      <currency value="USD"/>  
    </net>  
    <udi> 
      <reference value="#device-bridge"/> 
    </udi> 
    <bodySite> 
      <coding> 
        <system value="http://fdi.org/fhir/oraltoothcodes"/> 
        <code value="01"/> 
      </coding> 
    </bodySite> 
  </item> 

  <item> 
    <sequence value="2"/> 
    <careTeamSequence value="1"/> 
    <productOrService> 
      <coding> 
        <system value="http://example.org/fhir/oralservicecodes"/> 
        <code value="21211"/> 
      </coding> 
    </productOrService> 
    <servicedDate value="2014-08-16"/> 
    <locationCodeableConcept> 
      <coding> 
        <system value="http://terminology.hl7.org/CodeSystem/ex-serviceplace"/> 
        <code value="11"/> 
      </coding> 
    </locationCodeableConcept> 
    <unitPrice> 
      <value value="105.00"/> 
      <currency value="USD"/>  
    </unitPrice>  
    <net> 
      <value value="105.00"/> 
      <currency value="USD"/>  
    </net>  
    <bodySite> 
      <coding> 
        <system value="http://fdi.org/fhir/oraltoothcodes"/> 
        <code value="21"/> 
      </coding> 
    </bodySite> 
    <subSite> 
      <coding> 
        <system value="http://fdi.org/fhir/oralsurfacecodes"/> 
        <code value="L"/> 
      </coding> 
    </subSite> 
  </item> 

  <item> 
    <sequence value="3"/> 
    <careTeamSequence value="1"/> 
    <procedureSequence value="1"/> 
    <productOrService> 
      <coding> 
        <system value="http://example.org/fhir/oralservicecodes"/> 
        <code value="27211"/> 
      </coding> 
    </productOrService> 
    <servicedDate value="2014-08-16"/> 
    <locationCodeableConcept> 
      <coding> 
        <system value="http://terminology.hl7.org/CodeSystem/ex-serviceplace"/> 
        <code value="11"/> 
      </coding> 
    </locationCodeableConcept> 
    <unitPrice> 
      <value value="1100.00"/> 
      <currency value="USD"/>  
    </unitPrice>  
    <net> 
      <value value="1100.00"/> 
      <currency value="USD"/>  
    </net>  
    <bodySite> 
      <coding> 
        <system value="http://fdi.org/fhir/oraltoothcodes"/> 
        <code value="24"/> 
      </coding> 
    </bodySite> 

    <detail> 
      <sequence value="1"/> 
      <productOrService> 
        <coding> 
          <system value="http://example.org/fhir/oralservicecodes"/> 
          <code value="27211"/> 
        </coding> 
      </productOrService> 
      <unitPrice> 
        <value value="1000.00"/> 
        <currency value="USD"/>  
      </unitPrice>  
      <factor value="0.75"/>  <!--   Student discount   -->
      <net> 
        <value value="750.00"/> 
        <currency value="USD"/>  
      </net>  
    </detail> 

    <detail> 
      <sequence value="2"/> 
      <productOrService> 
        <coding> 
          <system value="http://example.org/fhir/oralservicecodes"/> 
          <code value="lab"/> 
        </coding> 
      </productOrService> 
      <unitPrice> 
        <value value="350.00"/> 
        <currency value="USD"/>  
      </unitPrice>  
      <net> 
        <value value="350.00"/> 
        <currency value="USD"/>  
      </net>  
    </detail> 
  </item> 
  <total> 
    <value value="2255.00"/> 
    <currency value="USD"/>  
  </total>  

</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.