2nd DSTU Draft For Comment

This page is part of the FHIR Specification (v0.4.0: DSTU 2 Draft). The current version which supercedes this version is 5.0.0. For a full list of available versions, see the Directory of published versions

Visionclaim-example-glasses.xml

Raw XML (canonical form)

Glasses Claim (id = "660151")

Raw XML

<VisionClaim xmlns="http://hl7.org/fhir">
  <id value="660151"/>
  <text>
    <status value="generated"/>
    <div xmlns="http://www.w3.org/1999/xhtml"><!-- Snipped for brevity --></div>
  </text>
  <identifier>
    <system value="http://happysight.com/claims"/>
    <value value="6612346"/>
  </identifier>
  <created value="2014-08-16"/>
  <target>
    <reference value="Organization/2"/>
  </target>
  <organization>
    <reference value="Organization/1"/>
  </organization>
  <use value="complete"/>
  <priority>
    <code value="normal"/>
  </priority>
  <prescription>
    <reference value="http://www.optdocs.com/prescription/12345"/>
  </prescription>
  <payee>
    <type>
      <code value="provider"/>
    </type>
  </payee>
  <diagnosis>
    <sequence value="1"/>
    <diagnosis>
      <code value="654321"/>
    </diagnosis>
  </diagnosis>
  <patient>
    <reference value="Patient/1"/>
  </patient>
  <coverage>
    <sequence value="1"/>
    <focal value="true"/>
    <coverage>
      <reference value="Coverage/9876B1"/>
    </coverage>
    <relationship>
      <code value="self"/>
    </relationship>
  </coverage>
  <item>
    <sequence value="1"/>
    <type>
      <code value="group"/>
    </type>
    <provider>
      <reference value="Practitioner/1"/>
    </provider>
    <service>
      <system value="http://hl7.org/fhir/ex-visionservice"/>
      <code value="glasses"/>
    </service>
    <serviceDate value="2014-08-16"/>
    <unitPrice>
      <value value="214.00"/>
      <system value="urn:std:iso:4217"/>
      <code value="USD"/>
    </unitPrice>
    <net>
      <value value="214.00"/>
      <system value="urn:std:iso:4217"/>
      <code value="USD"/>
    </net>
    <detail>
      <sequence value="1"/>
      <type>
        <code value="product"/>
      </type>
      <service>
        <system value="http://hl7.org/fhir/ex-visionservice"/>
        <code value="frame"/>
      </service>
      <unitPrice>
        <value value="100.00"/>
        <system value="urn:std:iso:4217"/>
        <code value="USD"/>
      </unitPrice>
      <net>
        <value value="100.00"/>
        <system value="urn:std:iso:4217"/>
        <code value="USD"/>
      </net>
    </detail>
    <detail>
      <sequence value="2"/>
      <type>
        <code value="product"/>
      </type>
      <service>
        <system value="http://hl7.org/fhir/ex-visionservice"/>
        <code value="lens"/>
      </service>
      <quantity>
        <value value="2"/>
      </quantity>
      <unitPrice>
        <value value="50.00"/>
        <system value="urn:std:iso:4217"/>
        <code value="USD"/>
      </unitPrice>
      <net>
        <value value="100.00"/>
        <system value="urn:std:iso:4217"/>
        <code value="USD"/>
      </net>
    </detail>
    <detail>
      <sequence value="3"/>
      <type>
        <code value="tax"/>
      </type>
      <service>
        <system value="http://hl7.org/fhir/ex-visionservice"/>
        <code value="fst"/>
      </service>
      <unitPrice>
        <value value="200.00"/>
        <system value="urn:std:iso:4217"/>
        <code value="USD"/>
      </unitPrice>
      <factor value="0.07"/>
      <net>
        <value value="14.00"/>
        <system value="urn:std:iso:4217"/>
        <code value="USD"/>
      </net>
    </detail>
  </item>
</VisionClaim>

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.