---
type: "example"
title: "Claim Example: claim-example-oral-bridge"
resource: "Claim"
example: "claim-example-oral-bridge"
---
# Claim Example: claim-example-oral-bridge

## Narrative

A human-readable rendering of the Oral Health Claim

## Example XML



```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>
```