Claim Example: claim-example-vision-glasses-3tier

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="660152"/>

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

    <contained>
        <Device>
            <id value="device-frame"/>
            <!-- rest of the resource omitted for brevity -->
        </Device>
    </contained>

    <contained>
        <Device>
            <id value="device-lens"/>
            <!-- rest of the resource omitted for brevity -->
        </Device>
    </contained>

    <identifier>
        <system value="http://happysight.com/claim"/>
        <value value="6612347"/>
    </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> <!-- Patient's own coverage - primary -->
        <sequence value="1"/>
        <focal value="false"/>
        <coverage>
            <reference value="Coverage/9876B1"/>
        </coverage>
        <preAuthRef value="PR7652387237"/>
        <claimResponse>
            <reference value="ClaimResponse/R3500"/>
        </claimResponse>
    </insurance>

    <insurance> <!-- Spouses's own coverage - secondary -->
        <sequence value="2"/>
        <focal value="true"/>
        <coverage>
            <reference value="Coverage/9876B1"/>
        </coverage>
        <preAuthRef value="AB543GTD7567"/>
    </insurance>

    <item>
        <sequence value="1"/>
        <careTeamSequence value="1"/>
        <revenue>
            <coding>
                <system value="http://terminology.hl7.org/CodeSystem/ex-revenue-center"/>
                <code value="0010"/>
                <display value ="Vision Clinic"/>
            </coding>
        </revenue>
        <category>
            <coding>
                <system value="http://example.org/fhir/CodeSystem/benefit-subcategory"/>
                <code value="F6"/>
                <display value ="Vision Coverage"/>
            </coding>
        </category>
        <productOrService>
            <coding>
                <system value="http://example.org/fhir/CodeSystem/ex-visionservice"/>
                <code value="glasses"/>
            </coding>
        </productOrService>
        <modifier>
            <coding>
                <system value="http://terminology.hl7.org/CodeSystem/modifiers"/>
                <code value="rooh"/>
            </coding>
        </modifier>
        <programCode>
            <coding>
                <system value="http://terminology.hl7.org/CodeSystem/ex-programcode"/>
                <code value="none"/>
            </coding>
        </programCode>
        <servicedDate value="2014-08-16"/>
        <unitPrice>
            <value value="235.40"/>
            <currency value="USD"/>
        </unitPrice>
        <net>
            <value value="235.40"/>
            <currency value="USD"/>
        </net>

        <detail>
            <sequence value="1"/>
            <revenue>
                <coding>
                    <system value="http://terminology.hl7.org/CodeSystem/ex-revenue-center"/>
                    <code value="0010"/>
                    <display value ="Vision Clinic"/>
                </coding>
            </revenue>
            <category>
                <coding>
                    <system value="http://example.org/fhir/CodeSystem/benefit-subcategory"/>
                    <code value="F6"/>
                    <display value ="Vision Coverage"/>
                </coding>
            </category>
            <productOrService>
                <coding>
                    <system value="http://example.org/fhir/CodeSystem/ex-visionservice"/>
                    <code value="frame"/>
                </coding>
            </productOrService>
            <modifier>
                <coding>
                    <system value="http://terminology.hl7.org/CodeSystem/modifiers"/>
                    <code value="rooh"/>
                </coding>
            </modifier>
            <unitPrice>
                <value value="100.00"/>
                <currency value="USD"/>
            </unitPrice>
            <factor value="1.1"/> <!-- 10% surcharge for out of hours work -->
            <net>
                <value value="110.00"/>
                <currency value="USD"/>
            </net>
            <udi>
                <reference value="#device-frame"/>
            </udi>
        </detail>

        <detail>
            <sequence value="2"/>
            <revenue>
                <coding>
                    <system value="http://terminology.hl7.org/CodeSystem/ex-revenue-center"/>
                    <code value="0010"/>
                    <display value ="Vision Clinic"/>
                </coding>
            </revenue>
            <category>
                <coding>
                    <system value="http://example.org/fhir/CodeSystem/benefit-subcategory"/>
                    <code value="F6"/>
                    <display value ="Vision Coverage"/>
                </coding>
            </category>
            <productOrService>
                <coding>
                    <system value="http://example.org/fhir/CodeSystem/ex-visionservice"/>
                    <code value="lens"/>
                </coding>
            </productOrService>
            <programCode>
                <coding>
                    <system value="http://terminology.hl7.org/CodeSystem/ex-programcode"/>
                    <code value="none"/>
                </coding>
            </programCode>
            <quantity>
                <value value="2"/>
            </quantity>
            <unitPrice>
                <value value="55.00"/>
                <currency value="USD"/>
            </unitPrice>
            <net>
                <value value="110.00"/>
                <currency value="USD"/>
            </net>

            <subDetail>
                <sequence value="1"/>
                <revenue>
                    <coding>
                        <system value="http://terminology.hl7.org/CodeSystem/ex-revenue-center"/>
                        <code value="0010"/>
                        <display value ="Vision Clinic"/>
                    </coding>
                </revenue>
                <category>
                    <coding>
                        <system value="http://example.org/fhir/CodeSystem/benefit-subcategory"/>
                        <code value="F6"/>
                        <display value ="Vision Coverage"/>
                    </coding>
                </category>
                <productOrService>
                    <coding>
                        <system value="http://example.org/fhir/CodeSystem/ex-visionservice"/>
                        <code value="lens"/>
                    </coding>
                </productOrService>
                <modifier>
                    <coding>
                        <system value="http://terminology.hl7.org/CodeSystem/modifiers"/>
                        <code value="rooh"/>
                    </coding>
                </modifier>
                <programCode>
                    <coding>
                        <system value="http://terminology.hl7.org/CodeSystem/ex-programcode"/>
                        <code value="none"/>
                    </coding>
                </programCode>
                <quantity>
                    <value value="2"/>
                </quantity>
                <unitPrice>
                    <value value="30.00"/>
                    <currency value="USD"/>
                </unitPrice>
                <factor value="1.1"/> <!-- 10% surchage for out of hours work -->
                <net>
                    <value value="66.00"/>
                    <currency value="USD"/>
                </net>
                <udi>
                    <reference value="#device-lens"/>
                </udi>
            </subDetail>

            <subDetail>
                <sequence value="2"/>
                <revenue>
                    <coding>
                        <system value="http://terminology.hl7.org/CodeSystem/ex-revenue-center"/>
                        <code value="0010"/>
                        <display value ="Vision Clinic"/>
                    </coding>
                </revenue>
                <category>
                    <coding>
                        <system value="http://example.org/fhir/CodeSystem/benefit-subcategory"/>
                        <code value="F6"/>
                        <display value ="Vision Coverage"/>
                    </coding>
                </category>
                <productOrService>
                    <coding>
                        <system value="http://example.org/fhir/CodeSystem/ex-visionservice"/>
                        <code value="hardening"/>
                    </coding>
                </productOrService>
                <modifier>
                    <coding>
                        <system value="http://terminology.hl7.org/CodeSystem/modifiers"/>
                        <code value="rooh"/>
                    </coding>
                </modifier>
                <quantity>
                    <value value="2"/>
                </quantity>
                <unitPrice>
                    <value value="15.00"/>
                    <currency value="USD"/>
                </unitPrice>
                <factor value="1.1"/> <!-- 10% surchage for out of hours work -->
                <net>
                    <value value="33.00"/>
                    <currency value="USD"/>
                </net>
            </subDetail>

            <subDetail>
                <sequence value="3"/>
                <revenue>
                    <coding>
                        <system value="http://terminology.hl7.org/CodeSystem/ex-revenue-center"/>
                        <code value="0010"/>
                        <display value ="Vision Clinic"/>
                    </coding>
                </revenue>
                <category>
                    <coding>
                        <system value="http://example.org/fhir/CodeSystem/benefit-subcategory"/>
                        <code value="F6"/>
                        <display value ="Vision Coverage"/>
                    </coding>
                </category>
                <productOrService>
                    <coding>
                        <system value="http://example.org/fhir/CodeSystem/ex-visionservice"/>
                        <code value="UV coating"/>
                    </coding>
                </productOrService>
                <modifier>
                    <coding>
                        <system value="http://terminology.hl7.org/CodeSystem/modifiers"/>
                        <code value="rooh"/>
                    </coding>
                </modifier>
                <quantity>
                    <value value="2"/>
                </quantity>
                <unitPrice>
                    <value value="5.00"/>
                    <currency value="USD"/>
                </unitPrice>
                <factor value="1.1"/> <!-- 10% surchage for out of hours work -->
                <net>
                    <value value="11.00"/>
                    <currency value="USD"/>
                </net>
            </subDetail>
        </detail>

        <detail>
            <sequence value="3"/>
            <revenue>
                <coding>
                    <system value="http://terminology.hl7.org/CodeSystem/ex-revenue-center"/>
                    <code value="0010"/>
                    <display value ="Vision Clinic"/>
                </coding>
            </revenue>
            <category>
                <coding>
                    <system value="http://example.org/fhir/CodeSystem/benefit-subcategory"/>
                    <code value="F6"/>
                    <display value ="Vision Coverage"/>
                </coding>
            </category>
            <productOrService>
                <coding>
                    <system value="http://example.org/fhir/CodeSystem/ex-visionservice"/>
                    <code value="fst"/>
                </coding>
            </productOrService>
            <unitPrice>
                <value value="220.00"/>
                <currency value="USD"/>
            </unitPrice>
            <factor value="0.07"/>
            <net>
                <value value="15.40"/>
                <currency value="USD"/>
            </net>
        </detail>
    </item>

</Claim>