Rich Institutional Service Claim (id = "960151")

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


  

  
    
    
  

  
    
    
  

  

  
    
      
      
    
  

  

  
    
  

  
    
    
  

  

  
    
      
      
    
  

  
    
  

  
    
      
      
    
  

  
    
      
    
  

  
    
      
        
      
    
  

  
    
      
      
    
  

  
    
    
      
    
    
    
      
        
        
      
    
    
      
        
        
      
    
  

  
    
    
      
        
        
      
    
    
      
      
    
  

  
    
    
      
        
        
      
    
    
      
      
    
  

  
    
    
      
        
      
    
    
      
        
        
      
    
    
      
        
        
        
      
    
  

  
    
    
    
      
    
    
    
  

  
    
    
      
        
        
        
      
    
    
      
    
  

  
    
    
    
      
        
         
      
    
    
    
      
       
     
    
      
       
     
  

  
    
      
  

<Claim xmlns="http://hl7.org/fhir">
  <id value="960151"/> 
  <text> 
    <status value="generated"/> 
    <div xmlns="http://www.w3.org/1999/xhtml">A human-readable rendering of the Claim</div> 
  </text> 
  <identifier> 
    <system value="http://happyhospital.com/claim"/> 
    <value value="96123451"/> 
  </identifier> 
  <status value="active"/> 
  <type> 
    <coding> 
      <system value="http://terminology.hl7.org/CodeSystem/claim-type"/> 
      <code value="institutional"/> 
    </coding> 
  </type> 
  <use value="claim"/> 
  <patient> 
    <reference value="Patient/1"/> 
  </patient> 
  <billablePeriod> 
    <start value="2014-08-15"/> 
    <end value="2014-08-16"/> 
  </billablePeriod> 
  <created value="2014-08-16"/> 
  <enterer> 
    <identifier> 
      <system value="http://jurisdiction.org/facilities/HOSP1234/users"/> 
      <value value="UC1234"/> 
    </identifier> 
  </enterer> 
  <insurer> 
    <reference value="Organization/2"/> 
  </insurer> 
  <provider> 
    <identifier> 
      <system value="http://npid.org/providerid"/> 
      <value value="NJ12345"/> 
    </identifier> 
  </provider> 
  <priority> 
    <coding> 
      <code value="normal"/> 
    </coding> 
  </priority> 
  <payee> 
    <type> 
      <coding> 
        <code value="provider"/> 
      </coding> 
    </type> 
  </payee> 
  <facility> 
    <identifier> 
      <system value="http://jurisdiction.org/facilities"/> 
      <value value="HOSP1234"/> 
    </identifier> 
  </facility> 
  <diagnosisRelatedGroup> 
    <coding> 
      <system value="http://terminology.hl7.org/CodeSystem/ex-diagnosisrelatedgroup"/> 
      <code value="400"/> 
      <display value="Head trauma - concussion"/> 
    </coding> 
  </diagnosisRelatedGroup> 
  
  <careTeam>     <sequence value="1"/>     <provider>       <reference value="Practitioner/example"/>     </provider>     <responsible value="true"/>     <role>       <coding>         <system value="http://example.org/fhir/CodeSystem/claim-careteamrole"/>         <code value="primary"/>       </coding>     </role>     <specialty>       <coding>         <system value="http://example.org/fhir/CodeSystem/provider-qualification"/>         <code value="physician"/>       </coding>     </specialty>   </careTeam>   <supportingInfo>     <sequence value="1"/>     <category>       <coding>         <system value="http://terminology.hl7.org/CodeSystem/claiminformationcategory"/>         <code value="employmentimpacted"/>       </coding>     </category>     <timingPeriod>       <start value="2014-08-16"/>       <end value="2014-08-16"/>     </timingPeriod>   </supportingInfo>   <supportingInfo>     <sequence value="2"/>     <category>       <coding>         <system value="http://terminology.hl7.org/CodeSystem/claiminformationcategory"/>         <code value="hospitalized"/>       </coding>     </category>     <timingPeriod>       <start value="2014-08-15"/>       <end value="2014-08-16"/>     </timingPeriod>   </supportingInfo>   <diagnosis>     <sequence value="1"/>     <diagnosisCodeableConcept>       <coding>         <code value="654456"/>       </coding>     </diagnosisCodeableConcept>     <type>       <coding>         <system value="http://terminology.hl7.org/CodeSystem/ex-diagnosistype"/>         <code value="admitting"/>       </coding>     </type>   </diagnosis>   <insurance>     <sequence value="1"/>     <focal value="true"/>     <coverage>       <reference value="Coverage/9876B1"/>     </coverage>     <businessArrangement value="BA987123"/>     <preAuthRef value="PA2014G56473"/>   </insurance>   <accident>     <date value="2014-07-09"/>     <type>       <coding>         <system value="http://terminology.hl7.org/CodeSystem/v3-ActIncidentCode"/>         <code value="SPT"/>         <display value="Sporting Accident"/>       </coding>     </type>     <locationAddress>       <text value="Grouse Mountain Ski Hill"/>     </locationAddress>   </accident>   <item>     <sequence value="1"/>     <careTeamSequence value="1"/>     <productOrService>       <coding>         <system value="http://hl7.org/fhir/ex-serviceproduct"/>         <code value="exam"/>        </coding>     </productOrService>     <servicedDate value="2014-08-16"/>     <unitPrice>       <value value="125.00"/>       <currency value="USD"/>      </unitPrice>      <net>       <value value="125.00"/>       <currency value="USD"/>      </net>    </item>   <total>     <value value="125.00"/>     <currency value="USD"/>     </total> 


</

Claim

>