Release 4B R5 Final QA

This page is part of the FHIR Specification (v4.3.0: R4B (v5.0.0-draft-final: Final QA Preview for R5 - STU see ballot notes ). 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-oral-orthoplan.xml

Example Claim/100153 (XML)

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

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

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PreAuthorization with Orthodontic Treatment Plan (id = "100153")

<?xml version="1.0" encoding="UTF-8"?> 
<?xml version="1.0" encoding="UTF-8"?>
<Claim xmlns="http://hl7.org/fhir">  <id value="100153"/>   <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="12355"/>   </identifier>   <status value="active"/>   <type>     <coding>       <system value="http://terminology.hl7.org/CodeSystem/claim-type"/>       <code value="oral"/>     </coding>   </type>   <use value="preauthorization"/>   <patient>     <reference value="Patient/1"/>   </patient>   <created value="2015-03-16"/>   <insurer>     <reference value="Organization/2"/>   </insurer>   <provider>     <reference value="Organization/1"/>   </provider>   <priority>     <coding>       <code value="normal"/>     </coding>   </priority>   <fundsReserve>     <coding>       <code value="provider"/>     </coding>   </fundsReserve>   <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>         <system value="http://hl7.org/fhir/sid/icd-10"/>           <!--   <code value="123457"/>   -->        <code value="K07.3"/>       </coding>     </diagnosisCodeableConcept>   </diagnosis>   <insurance>     <sequence value="1"/>     <focal value="true"/>     <coverage>       <reference value="Coverage/9876B1"/>     </coverage>   </insurance>   <item>     <sequence value="1"/>     <careTeamSequence value="1"/>     <diagnosisSequence value="1"/>     <productOrService>       <coding>         <system value="http://example.org/fhir/oralservicecodes"/>         <code value="ORTHPLAN"/>       </coding>     </productOrService>     <servicedDate value="2015-05-16"/>     <!--   Start Date   -->    <unitPrice>       <value value="9000.00"/>       <currency value="USD"/>      </unitPrice>      <net>       <value value="9000.00"/>       <currency value="USD"/>      </net>      <detail>       <sequence value="1"/>    <!--   Exam Fee   -->      <productOrService>         <coding>           <system value="http://example.org/fhir/oralservicecodes"/>           <code value="ORTHOEXAM"/>         </coding>       </productOrService>       <unitPrice>         <value value="1000.00"/>         <currency value="USD"/>        </unitPrice>        <net>         <value value="1000.00"/>         <currency value="USD"/>        </net>      </detail>     <detail>       <sequence value="2"/>    <!--   Diagnostic Fee   -->      <productOrService>         <coding>           <system value="http://example.org/fhir/oralservicecodes"/>           <code value="ORTHODIAG"/>         </coding>       </productOrService>       <unitPrice>         <value value="1500.00"/>         <currency value="USD"/>        </unitPrice>        <net>         <value value="1500.00"/>         <currency value="USD"/>        </net>      </detail>     <detail>       <sequence value="3"/>    <!--   Initial Payment   -->      <productOrService>         <coding>           <system value="http://example.org/fhir/oralservicecodes"/>           <code value="ORTHOINITIAL"/>         </coding>       </productOrService>       <unitPrice>         <value value="500.00"/>         <currency value="USD"/>        </unitPrice>        <net>         <value value="500.00"/>         <currency value="USD"/>        </net>      </detail>     <detail>       <sequence value="4"/>    <!--   Duration in Months   -->      <productOrService>         <coding>           <system value="http://example.org/fhir/oralservicecodes"/>           <code value="ORTHOMONTHS"/>         </coding>       </productOrService>       <quantity>         <value value="24"/>       </quantity>       </detail>     <detail>       <sequence value="5"/>    <!--   Periodic Payments   -->      <productOrService>         <coding>           <system value="http://example.org/fhir/oralservicecodes"/>           <code value="ORTHOPERIODIC"/>         </coding>       </productOrService>       <quantity>         <value value="24"/>       </quantity>         <unitPrice>         <value value="250.00"/>         <currency value="USD"/>        </unitPrice>        <net>         <value value="250.00"/>         <currency value="USD"/>        </net>      </detail>   </item>   <item>     <sequence value="2"/>     <careTeamSequence value="1"/>     <productOrService>       <coding>         <system value="http://example.org/fhir/oralservicecodes"/>         <code value="21211"/>       </coding>     </productOrService>     <servicedDate value="2014-08-16"/>     <unitPrice>       <value value="105.00"/>       <currency value="USD"/>      </unitPrice>      <net>       <value value="105.00"/>       <currency value="USD"/>      </net>      <bodySite>       <site>         <concept>           <coding>             <system value="http://fdi.org/fhir/oraltoothcodes"/>             <code value="21"/>           </coding>         </concept>       </site>       <subSite>         <coding>           <system value="http://fdi.org/fhir/oralsurfacecodes"/>           <code value="L"/>         </coding>       </subSite>     </bodySite>   </item>   <item>     <sequence value="3"/>     <careTeamSequence value="1"/>     <productOrService>       <coding>         <system value="http://example.org/fhir/oralservicecodes"/>         <code value="27211"/>       </coding>     </productOrService>     <servicedDate value="2014-08-16"/>     <unitPrice>       <value value="1100.00"/>       <currency value="USD"/>      </unitPrice>      <net>       <value value="1100.00"/>       <currency value="USD"/>      </net>      <bodySite>       <site>         <concept>           <coding>             <system value="http://fdi.org/fhir/oraltoothcodes"/>             <code value="36"/>           </coding>         </concept>       </site>     </bodySite>     <detail>       <sequence value="1"/>       <productOrService>         <coding>           <system value="http://example.org/fhir/oralservicecodes"/>           <code value="27211"/>         </coding>       </productOrService>       <unitPrice>         <value value="750.00"/>         <currency value="USD"/>        </unitPrice>        <net>         <value value="750.00"/>         <currency value="USD"/>        </net>      </detail>     <detail>       <sequence value="2"/>       <productOrService>         <coding>           <system value="http://example.org/fhir/oralservicecodes"/>           <code value="lab"/>         </coding>       </productOrService>       <unitPrice>         <value value="350.00"/>         <currency value="USD"/>        </unitPrice>        <net>         <value value="350.00"/>         <currency value="USD"/>        </net>      </detail>   </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.