FHIR Release 3 (STU)

This page is part of the FHIR Specification (v3.0.2: STU 3). 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 R2

Claim-example-vision-glasses.xml

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

Raw XML (canonical form)

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Glasses Claim (id = "660151")

<Claim xmlns="http://hl7.org/fhir">
 <id value="660151"/> 

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

  <identifier> 
    <system value="http://happysight.com/claim"/> 
    <value value="6612346"/> 
 </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> 
   <sequence value="1"/> 
   <focal value="true"/> 
   <coverage> 
     <reference value="Coverage/9876B1"/> 
   </coverage> 
 </insurance> 
  
 <item> 
   <sequence value="1"/> 
   <careTeamLinkId value="1"/> 
   <service> 
    <coding> 
     <system value="http://hl7.org/fhir/ex-visionservice"/> 
     <code value="glasses"/> 
    </coding> 
   </service> 
   <servicedDate value="2014-08-16"/> 
   <unitPrice> 
      <value value="214.00"/> 
    <system value="urn:iso:std:iso:4217"/> 
      <code value="USD"/>  
   </unitPrice>  
   <net> 
      <value value="214.00"/> 
    <system value="urn:iso:std:iso:4217"/> 
      <code value="USD"/>  
   </net>  
   <detail> 
     <sequence value="1"/> 
     <service> 
    <coding> 
       <system value="http://hl7.org/fhir/ex-visionservice"/> 
       <code value="frame"/> 
      </coding> 
   </service> 
     <unitPrice> 
       <value value="100.00"/> 
       <system value="urn:iso:std:iso:4217"/> 
       <code value="USD"/>  
     </unitPrice>  
     <net> 
       <value value="100.00"/> 
       <system value="urn:iso:std:iso:4217"/> 
       <code value="USD"/>  
     </net>  
   </detail> 
   <detail> 
     <sequence value="2"/> 
     <service> 
    <coding> 
       <system value="http://hl7.org/fhir/ex-visionservice"/> 
       <code value="lens"/> 
      </coding> 
   </service> 
     <quantity> 
       <value value="2"/> 
     </quantity> 
     <unitPrice> 
       <value value="50.00"/> 
       <system value="urn:iso:std:iso:4217"/> 
       <code value="USD"/>  
     </unitPrice>  
     <net> 
       <value value="100.00"/> 
       <system value="urn:iso:std:iso:4217"/> 
       <code value="USD"/>  
     </net>  
   </detail> 
   <detail> 
     <sequence value="3"/> 
     <service> 
    <coding> 
       <system value="http://hl7.org/fhir/ex-visionservice"/> 
       <code value="fst"/> 
      </coding> 
   </service> 
     <unitPrice> 
       <value value="200.00"/> 
       <system value="urn:iso:std:iso:4217"/> 
       <code value="USD"/>  
     </unitPrice>  
     <factor value="0.07"/> 
     <net> 
       <value value="14.00"/> 
       <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.