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

## 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/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>
```