Claim Example: claim-example-oral-orthoplan

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/coverage.xsd">
    <id value="100153"/>

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

    <identifier>
        <system value="http://happyvalley.com/claim"/>
        <value value="12355"/>
    </identifier>

    <status value = "active"/>

    <type>
        <coding>
            <system value="http://terminology.hl7.org/CodeSystem/claim-type"/>
            <code value="oral"/>
        </coding>
    </type>

    <use value="preauthorization"/>

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

    <created value="2015-03-16"/>

    <insurer>
        <reference value="Organization/2"/>
    </insurer>

    <provider>
        <reference value="Organization/1"/>
    </provider>

    <priority>
        <coding>
            <code value="normal"/>
        </coding>
    </priority>

    <fundsReserve>
        <coding>
            <code value="provider"/>
        </coding>
    </fundsReserve>

    <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>
                <system value="http://hl7.org/fhir/sid/icd-10"/>
                <!-- <code value="123457"/> -->
                <code value="K07.3"/>
            </coding>
        </diagnosisCodeableConcept>
    </diagnosis>

    <insurance>
        <sequence value="1"/>
        <focal value="true"/>
        <coverage>
            <reference value="Coverage/9876B1"/>
        </coverage>
    </insurance>

    <item>
        <sequence value="1"/>
        <careTeamSequence value="1"/>
        <diagnosisSequence value="1"/>
        <productOrService>
            <coding>
                <system value="http://example.org/fhir/oralservicecodes"/>
                <code value="ORTHPLAN"/>
            </coding>
        </productOrService>
        <servicedDate value="2015-05-16"/>  <!-- Start Date -->
        <unitPrice>
            <value value="9000.00"/>
            <currency value="USD"/>
        </unitPrice>
        <net>
            <value value="9000.00"/>
            <currency value="USD"/>
        </net>
        <detail>
            <sequence value="1"/> <!-- Exam Fee -->
            <productOrService>
                <coding>
                    <system value="http://example.org/fhir/oralservicecodes"/>
                    <code value="ORTHOEXAM"/>
                </coding>
            </productOrService>
            <unitPrice>
                <value value="1000.00"/>
                <currency value="USD"/>
            </unitPrice>
            <net>
                <value value="1000.00"/>
                <currency value="USD"/>
            </net>
        </detail>
        <detail>
            <sequence value="2"/> <!-- Diagnostic Fee -->
            <productOrService>
                <coding>
                    <system value="http://example.org/fhir/oralservicecodes"/>
                    <code value="ORTHODIAG"/>
                </coding>
            </productOrService>
            <unitPrice>
                <value value="1500.00"/>
                <currency value="USD"/>
            </unitPrice>
            <net>
                <value value="1500.00"/>
                <currency value="USD"/>
            </net>
        </detail>
        <detail>
            <sequence value="3"/> <!-- Initial Payment -->
            <productOrService>
                <coding>
                    <system value="http://example.org/fhir/oralservicecodes"/>
                    <code value="ORTHOINITIAL"/>
                </coding>
            </productOrService>
            <unitPrice>
                <value value="500.00"/>
                <currency value="USD"/>
            </unitPrice>
            <net>
                <value value="500.00"/>
                <currency value="USD"/>
            </net>
        </detail>
        <detail>
            <sequence value="4"/> <!-- Duration in Months -->
            <productOrService>
                <coding>
                    <system value="http://example.org/fhir/oralservicecodes"/>
                    <code value="ORTHOMONTHS"/>
                </coding>
            </productOrService>
            <quantity>
                <value value="24"/>
            </quantity>
        </detail>
        <detail>
            <sequence value="5"/> <!-- Periodic Payments -->
            <productOrService>
                <coding>
                    <system value="http://example.org/fhir/oralservicecodes"/>
                    <code value="ORTHOPERIODIC"/>
                </coding>
            </productOrService>
            <quantity>
                <value value="24"/>
            </quantity>
            <unitPrice>
                <value value="250.00"/>
                <currency value="USD"/>
            </unitPrice>
            <net>
                <value value="250.00"/>
                <currency value="USD"/>
            </net>
        </detail>
    </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"/>
        <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"/>
        <productOrService>
            <coding>
                <system value="http://example.org/fhir/oralservicecodes"/>
                <code value="27211"/>
            </coding>
        </productOrService>
        <servicedDate value="2014-08-16"/>
        <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="36"/>
                    </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="750.00"/>
                <currency value="USD"/>
            </unitPrice>
            <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>

</Claim>