Claim Example: claim-example-oral-bridge

Narrative

A human-readable rendering of the Oral Health Claim

Example XML

<?xml version="1.0" encoding="UTF-8"?>
<Claim xmlns="http://hl7.org/fhir" xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance"
    xsi:schemaLocation="http://hl7.org/fhir ../../schema/claim.xsd">
    <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 omitted 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"/>

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

    <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>
        <timingDateTime 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>
            <site>
                <concept>
                    <coding>
                        <system value="http://fdi.org/fhir/oraltoothcodes"/>
                        <code value="01"/>
                    </coding>
                </concept>
            </site>
        </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>
            <site>
                <concept>
                    <coding>
                        <system value="http://fdi.org/fhir/oraltoothcodes"/>
                        <code value="21"/>
                    </coding>
                </concept>
            </site>
            <subSite>
                <coding>
                    <system value="http://fdi.org/fhir/oralsurfacecodes"/>
                    <code value="L"/>
                </coding>
            </subSite>
        </bodySite>
    </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>
            <site>
                <concept>
                    <coding>
                        <system value="http://fdi.org/fhir/oraltoothcodes"/>
                        <code value="24"/>
                    </coding>
                </concept>
            </site>
        </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>