Claim Example: claim-example-oral-contained

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">
    <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"/>

            <kind value="insurance"/>

            <type>
                <coding>
                    <system value="http://terminology.hl7.org/CodeSystem/v3-ActCode"/>
                    <code value="EHCPOL"/>
                </coding>
            </type>

            <subscriber>
                <reference value="#patient-1"/>
            </subscriber>

            <beneficiary>
                <reference value="#patient-1"/>
            </beneficiary>
            <dependent value="1"/>

            <relationship>
                <coding>
                    <code value="self"/>
                </coding>
            </relationship>

            <insurer>
                <identifier>
                    <system value="http://www.bindb.com/bin"/>
                    <value value="123456"/>
                </identifier>
            </insurer>

            <class>
                <type>
                    <coding>
                        <system value="http://terminology.hl7.org/CodeSystem/coverage-class"/>
                        <code value="plan"/>
                    </coding>
                </type>
                <value>
                    <value value="CBI35"/>
                </value>
                <name value="Corporate Baker's Inc. Plan#35"/>
            </class>

            <class>
                <type>
                    <coding>
                        <system value="http://terminology.hl7.org/CodeSystem/coverage-class"/>
                        <code value="subplan"/>
                    </coding>
                </type>
                <value>
                    <value value="123"/>
                </value>
                <name value="Trainee Part-time Benefits"/>
            </class>

            <class>
                <type>
                    <coding>
                        <system value="http://terminology.hl7.org/CodeSystem/coverage-class"/>
                        <code value="sequence"/>
                    </coding>
                </type>
                <value>
                    <value value="1"/>
                </value>
            </class>

        </Coverage>
    </contained>

    <identifier>
        <system value="http://happyvalley.com/claim"/>
        <value value="12347"/>
    </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="#org-insurer"/>
    </insurer>

    <provider>
        <reference value="#org-org"/>
    </provider>

    <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"/>
        <careTeamSequence value="1"/>
        <productOrService>
            <coding>
                <code value="1200"/>
            </coding>
        </productOrService>
        <servicedDate value="2014-08-16"/>
        <unitPrice>
            <value value="135.57"/>
            <currency value="USD"/>
        </unitPrice>
        <net>
            <value value="135.57"/>
            <currency value="USD"/>
        </net>
    </item>
</Claim>