Claim-example-institutional-rich.xml

Rich Institutional Service Claim (id = "960151")

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

<Claim xmlns="http://hl7.org/fhir">
  <id value="960151"/> 

  <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="96123451"/> 
  </identifier> 

  <status value="active"/> 

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

  <use value="claim"/> 

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

  <billablePeriod> 
    <start value="2014-08-15"/> 
    <end value="2014-08-16"/> 
  </billablePeriod> 

  <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> 
    <identifier> 
      <system value="http://npid.org/providerid"/> 
      <value value="NJ12345"/> 
    </identifier> 
  </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> 
    <responsible value="true"/> 
    <role> 
      <coding> 
        <system value="http://example.org/fhir/CodeSystem/claim-careteamrole"/> 
        <code value="primary"/> 
      </coding> 
    </role> 
    <qualification> 
      <coding> 
        <system value="http://example.org/fhir/CodeSystem/provider-qualification"/> 
        <code value="physician"/> 
      </coding> 
    </qualification> 
  </careTeam> 

  <supportingInfo> 
    <sequence value="1"/> 
    <category> 
      <coding> 
        <system value="http://terminology.hl7.org/CodeSystem/claiminformationcategory"/> 
        <code value="employmentimpacted"/> 
      </coding> 
    </category> 
    <timingPeriod> 
      <start value="2014-08-16"/> 
      <end value="2014-08-16"/> 
    </timingPeriod> 
  </supportingInfo> 

  <supportingInfo> 
    <sequence value="2"/> 
    <category> 
      <coding> 
        <system value="http://terminology.hl7.org/CodeSystem/claiminformationcategory"/> 
        <code value="hospitalized"/> 
      </coding> 
    </category> 
    <timingPeriod> 
      <start value="2014-08-15"/> 
      <end value="2014-08-16"/> 
    </timingPeriod> 
  </supportingInfo> 

  <diagnosis> 
    <sequence value="1"/> 
    <diagnosisCodeableConcept> 
      <coding> 
        <code value="654456"/> 
      </coding> 
    </diagnosisCodeableConcept> 
    <type> 
      <coding> 
        <system value="http://terminology.hl7.org/CodeSystem/ex-diagnosistype"/> 
        <code value="admitting"/> 
      </coding> 
    </type> 
    <packageCode> 
      <coding> 
        <system value="http://terminology.hl7.org/CodeSystem/ex-diagnosisrelatedgroup"/> 
        <code value="400"/> 
        <display value="Head trauma - concussion"/> 
      </coding> 
    </packageCode> 
  </diagnosis> 

  <insurance> 
    <sequence value="1"/> 
    <focal value="true"/> 
    <coverage> 
      <reference value="Coverage/9876B1"/> 
    </coverage> 
    <businessArrangement value="BA987123"/> 
    <preAuthRef value="PA2014G56473"/> 
  </insurance> 

  <accident> 
    <date value="2014-07-09"/> 
    <type> 
      <coding> 
        <system value="http://terminology.hl7.org/CodeSystem/v3-ActIncidentCode"/> 
        <code value="SPT"/> 
        <display value="Sporting Accident"/> 
      </coding> 
    </type> 
    <locationAddress> 
      <text value="Grouse Mountain Ski Hill"/> 
    </locationAddress> 
  </accident> 

  <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>  
  </item> 

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