Claim Example: claim-example-vision-glasses

Narrative

A human-readable rendering of the Vision Claim for Glasses

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="660151"/>

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

    <identifier>
        <system value="http://happysight.com/claim"/>
        <value value="6612346"/>
    </identifier>

    <status value = "active"/>

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

    <prescription>
        <reference value="http://www.optdocs.com/prescription/12345"/>
    </prescription>

    <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>
                <code value="654321"/>
            </coding>
        </diagnosisCodeableConcept>
    </diagnosis>

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

    <item>
        <sequence value="1"/>
        <careTeamSequence value="1"/>
        <productOrService>
            <coding>
                <system value="http://example.org/fhir/CodeSystem/ex-visionservice"/>
                <code value="glasses"/>
            </coding>
        </productOrService>
        <servicedDate value="2014-08-16"/>
        <unitPrice>
            <value value="214.00"/>
            <currency value="USD"/>
        </unitPrice>
        <net>
            <value value="214.00"/>
            <currency value="USD"/>
        </net>
        <detail>
            <sequence value="1"/>
            <productOrService>
                <coding>
                    <system value="http://example.org/fhir/CodeSystem/ex-visionservice"/>
                    <code value="frame"/>
                </coding>
            </productOrService>
            <unitPrice>
                <value value="100.00"/>
                <currency value="USD"/>
            </unitPrice>
            <net>
                <value value="100.00"/>
                <currency value="USD"/>
            </net>
        </detail>
        <detail>
            <sequence value="2"/>
            <productOrService>
                <coding>
                    <system value="http://example.org/fhir/CodeSystem/ex-visionservice"/>
                    <code value="lens"/>
                </coding>
            </productOrService>
            <quantity>
                <value value="2"/>
            </quantity>
            <unitPrice>
                <value value="50.00"/>
                <currency value="USD"/>
            </unitPrice>
            <net>
                <value value="100.00"/>
                <currency value="USD"/>
            </net>
        </detail>
        <detail>
            <sequence value="3"/>
            <productOrService>
                <coding>
                    <system value="http://example.org/fhir/CodeSystem/ex-visionservice"/>
                    <code value="fst"/>
                </coding>
            </productOrService>
            <unitPrice>
                <value value="200.00"/>
                <currency value="USD"/>
            </unitPrice>
            <factor value="0.07"/>
            <net>
                <value value="14.00"/>
                <currency value="USD"/>
            </net>
        </detail>
    </item>

</Claim>