Claim-example-oral-contained.xml

SOA Dental Claim (Contained) (id = "100152")

<Claim xmlns="http://hl7.org/fhir">
  <id value="100152"/> 
  <text> 
    <status value="generated"/> 
    <div xmlns="http://www.w3.org/1999/xhtml">A human-readable rendering of the Oral Health Claim</div> 
  </text> 
  
  <contained> 
    <Organization> 
      <id value="org-insurer"/> 
      <identifier> 
        <system value="http://www.bindb.com/bin"/> 
        <value value="123456"/> 
      </identifier> 
    </Organization> 
  </contained> 

  <contained> 
    <Organization> 
      <id value="org-org"/> 
      <identifier> 
        <system value="http://www.jurisdiction.com/oralhealthoffices"/> 
        <value value="3456"/> 
      </identifier> 
    </Organization> 
  </contained> 

  <contained> 
    <Practitioner> 
      <id value="provider-1"/> 
      <identifier> 
        <system value="http://www.jurisdiction.com/oralhealthproviders"/> 
        <value value="123456789"/> 
      </identifier> 
    </Practitioner> 
  </contained> 
 
  <contained> 
    <Patient> 
      <id value="patient-1"/> 
      <name> 
        <use value="official"/> 
        <family value="Donald"/> 
        <given value="Duck"/> 
      </name> 
      <gender value="male"/> 
      <birthDate value="1986-05-17"/> 
      <address> 
        <use value="home"/> 
        <line value="1234 Main Street"/> 
        <city value="Vancouver"/> 
        <postalCode value="V2H1Y3"/> 
        <country value="CAD"/> 
      </address> 
    </Patient> 
  </contained> 
  
  <contained> 
    <Coverage> 
      <id value="coverage-1"/> 
    
      <identifier> 
        <system value="http://benefitsinc.com/certificate"/> 
        <value value="12345"/> 
      </identifier> 

      <status value="active"/> 

      <type> 
     <coding> 
        <system value="http://hl7.org/fhir/v3/ActCode"/> 
        <code value="EHCPOL"/> 
       </coding> 
    </type> 
    
      <subscriber> 
        <reference value="#patient-1"/> 
      </subscriber> 
 
      <beneficiary> 
        <reference value="#patient-1"/> 
      </beneficiary> 
 
      <relationship> 
     <coding> 
        <code value="self"/> 
       </coding> 
    </relationship> 

      <payor> 
      <identifier> 
          <system value="http://www.bindb.com/bin"/> 
          <value value="123456"/> 
      </identifier> 
      </payor> 
    
    <grouping> 
      <plan value="CBI35"/> 
        <planDisplay value="Corporate Baker's Inc. Plan#35"/> 
        <subPlan value="123"/> 
        <subPlanDisplay value="Trainee Part-time Benefits"/> 
    </grouping>  
        
      <dependent value="1"/> 
      <sequence value="1"/> 
    </Coverage> 
  </contained> 
  
  <identifier> 
    <system value="http://happyvalley.com/claim"/> 
    <value value="12347"/> 
  </identifier> 
  
  <status value="active"/> 
  
  <type> 
   <coding> 
    <system value="http://hl7.org/fhir/ex-claimtype"/> 
    <code value="oral"/> 
   </coding> 
  </type> 

  <use value="complete"/> 
  
  <patient> 
    <reference value="#patient-1"/> 
  </patient> 

  <created value="2014-08-16"/> 
  
  <insurer> 
    <reference value="#org-insurer"/> 
  </insurer> 
  
  <organization> 
    <reference value="#org-org"/> 
  </organization>   
  
  <priority> 
   <coding> 
    <code value="normal"/> 
   </coding> 
  </priority> 
  
  <payee> 
    <type> 
   <coding> 
      <code value="provider"/> 
     </coding> 
  </type> 
  </payee> 

   <careTeam> 
    <sequence value="1"/> 
    <provider> 
      <reference value="#provider-1"/> 
    </provider> 
   </careTeam> 
  
  <diagnosis> 
    <sequence value="1"/> 
    <diagnosisCodeableConcept> 
   <coding> 
      <code value="123456"/> 
     </coding> 
  </diagnosisCodeableConcept> 
  </diagnosis> 
  
  <insurance> 
    <sequence value="1"/> 
    <focal value="true"/> 
    <coverage> 
      <reference value="#coverage-1"/> 
    </coverage> 
  </insurance> 
  
  <item> 
    <sequence value="1"/> 
    <careTeamLinkId value="1"/> 
    <service> 
   <coding> 
      <code value="1200"/> 
     </coding> 
  </service> 
    <servicedDate value="2014-08-16"/> 
    <unitPrice> 
      <value value="135.57"/> 
      <system value="urn:iso:std:iso:4217"/> 
      <code value="USD"/> 
    </unitPrice> 
    <net> 
      <value value="135.57"/> 
      <system value="urn:iso:std:iso:4217"/> 
      <code value="USD"/> 
    </net> 
  </item> 
</Claim>