---
type: "example"
title: "Claim Example: claim-example-vision-glasses-3tier"
resource: "Claim"
example: "claim-example-vision-glasses-3tier"
---
# Claim Example: claim-example-vision-glasses-3tier

## Narrative

A human-readable rendering of the Vision Claim for Glasses

## 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="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>
```