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

## 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="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>
```