FHIR Release 3 (STU) R4 Ballot #2 (Mixed Normative/Trial use)

This page is part of the FHIR Specification (v3.0.2: STU 3). (v3.5.0: R4 Ballot #2). The current version which supercedes this version is 5.0.0 . For a full list of available versions, see the Directory of published versions . Page versions: R5 R4B R4 R3 R2

Claim-example.xml

Financial Management Work Group Maturity Level : N/A Ballot Status : Informative Compartments : Encounter , Patient , Practitioner , RelatedPerson

Raw XML ( canonical form + also see XML Format Specification )

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Simple dental Claim (id = "100150") 

<?xml version="1.0" encoding="UTF-8"?>


<Claim xmlns="http://hl7.org/fhir">
  <id value="100150"/> 

  <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="12345"/> 
  </identifier> 
 



  <status value="active"/> 

  <type> 
   
    
    
     

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


  <use value="claim"/> 

  <patient> 
    <reference value="Patient/1"/> 
  </patient> 
 



  <created value="2014-08-16"/> 

  <insurer> 
    <reference value="Organization/2"/> 
  </insurer> 

  
    
  

  <provider> 
    <reference value="Organization/1"/> 
  </provider> 

  <priority> 
   
    
   

    <coding> 
      <code value="normal"/> 
    </coding> 
  </priority> 

  <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="123456"/> 
      </coding>  
    </diagnosisCodeableConcept> 
  </diagnosis> 
 



  <insurance> 
    <sequence value="1"/> 
    <focal value="true"/> 
    <identifier> 
      <system value="http://happyvalley.com/claim"/> 
      <value value="12345"/> 
    </identifier> 
    <coverage> 
      <reference value="Coverage/9876B1"/> 
    </coverage> 
  </insurance> 
  
 
   
   
   
    
     
   
   
   
   
      
      
       
    
   
      
      
       
    


  <item> 
    <sequence value="1"/> 
    <careTeamSequence value="1"/> 
    <billcode> 
      <coding> 
        <code value="1200"/> 
      </coding>  
    </billcode> 
    <servicedDate value="2014-08-16"/> 
    <unitPrice> 
      <value value="135.57"/> 
      <currency value="USD"/>  
    </unitPrice>  
    <net> 
      <value value="135.57"/> 
      <currency value="USD"/>  
    </net>  
  </item> 



</

Claim

>

Usage note: every effort has been made to ensure that the examples are correct and useful, but they are not a normative part of the specification.