Release 4 5

This page is part of the FHIR Specification (v4.0.1: R4 (v5.0.0: R5 - Mixed Normative and STU ) ). This is the current published version in it's permanent home (it will always be available at this URL). 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

Claim-example-oral-bridge.xml

Example Claim/100156 (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 )

Jump past Narrative

PreAuthorization with Bridge and Crown (id = "100156") 

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


  

  
    
    
  

  
    
      
      
    
  

  
    
      
      
      
      
        
      
      
    
  

  
    
    
  

  

  
    
      
      
    
  

  

  
    
  

  

  
    
  

  
    
  

  
    
      
    
  

  
    
      
    
    
      
        
        
      
    
    
      
    
  

  
    
      
        
        
      
    
    
      
    
  

  
    
  

  
    
    
      
    
  

  
    
    
      
        
        
      
    
    
      
        
        
        
      
    
    
  

  
       
    
    
      
    
  

  
    
    
    
      
    
  

  
    
    
    
    
      
        
        
        
      
    
    
    
      
        
        
      
    
    
      
       
     
    
    
      
       
     
    
      
    
    
      
        
        
      
    
  

  
    
    
    
      
        
        
      
    
    
    
      
        
        
      
    
    
      
       
     
    
      
       
     
    
      
        
        
      
    
    
      
        
        
      
    
  

  
    
    
    
    
      
        
        
      
    
    
    
      
        
        
      
    
    
      
       
     
    
      
       
     
    
      
        
        
      
    

    
      
      
        
          
          
        
      
      
        
         
       
      
      
        
         
       
    

    
      
      
        
          
          
        
      
      
        
         
       
      
        
         
       
    
  
  
    
     
   


<Claim xmlns="http://hl7.org/fhir">
  <id value="100156"/> 
  <text> 
    <status value="generated"/> 
    <div xmlns="http://www.w3.org/1999/xhtml">A human-readable rendering of the Oral Health Claim</div> 
  </text> 
  <contained> 
    <Device> 
      <id value="device-bridge"/> 
        <!--   rest of the resource ommitted for brevity   -->
    </Device> 
  </contained> 
  <contained> 
    <ServiceRequest> 
      <id value="referral"/> 
      <status value="active"/> 
      <intent value="order"/> 
      <subject> 
        <reference value="Patient/1"/> 
      </subject> 
        <!--   rest of the resource omitted for brevity   -->
    </ServiceRequest> 
  </contained> 
  <identifier> 
    <system value="http://happyvalley.com/claim"/> 
    <value value="123466"/> 
  </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> 
  <related> 
    <claim> 
      <reference value="Claim/100151"/> 
    </claim> 
    <relationship> 
      <coding> 
        <system value="http://terminology.hl7.org/CodeSystem/ex-relatedclaimrelationship"/> 
        <code value="associated"/> 
      </coding> 
    </relationship> 
    <reference> 
      <value value="CASE156746B"/>    <!--   case number   -->
    </reference> 
  </related> 
  <payee> 
    <type> 
      <coding> 
        <system value="http://terminology.hl7.org/CodeSystem/payeetype"/> 
        <code value="other"/> 
      </coding> 
    </type> 
    <party> 
      <reference value="RelatedPerson/peter"/> 
    </party> 
  </payee> 
  <referral> 
    <reference value="#referral"/> 
  </referral> 
  <careTeam> 
    <sequence value="1"/> 
    <provider> 
      <reference value="Practitioner/example"/> 
    </provider> 
  </careTeam> 
  <supportingInfo> 
    <sequence value="1"/> 
    <category> 
      <coding> 
        <system value="http://terminology.hl7.org/CodeSystem/claiminformationcategory"/> 
        <code value="prosthesis"/> 
      </coding> 
    </category> 
    <code> 
      <coding> 
        <system value="http://hl7.org/fhir/ex-oralprostho"/> 
        <code value="2"/> 
        <display value="Maryland Bridge"/> 
      </coding> 
    </code> 
    <timingDate value="2001-04-07"/>    <!--   original placement   -->
  </supportingInfo> 
  <procedure> 
    <sequence value="1"/>    
    <date value="2014-07-04"/> 
    <procedureCodeableConcept> 
      <text value="Resection of gum to increase exposed tooth."/> 
    </procedureCodeableConcept> 
  </procedure> 
  <insurance> 
    <sequence value="1"/> 
    <focal value="true"/> 
    <coverage> 
      <reference value="Coverage/9876B1"/> 
    </coverage> 
  </insurance> 
  <item> 
    <sequence value="1"/> 
    <careTeamSequence value="1"/> 
    <informationSequence value="1"/> 
    <productOrService> 
      <coding> 
        <system value="http://example.org/fhir/oralservicecodes"/> 
        <code value="67221"/> 
        <display value="Maryland Bridge"/> 
      </coding> 
    </productOrService> 
    <servicedDate value="2014-08-16"/> 
    <locationCodeableConcept> 
      <coding> 
        <system value="http://terminology.hl7.org/CodeSystem/ex-serviceplace"/> 
        <code value="11"/> 
      </coding> 
    </locationCodeableConcept> 
    <unitPrice> 
      <value value="1400.00"/> 
      <currency value="USD"/>  
    </unitPrice>  
    <factor value="0.75"/>    <!--   student discount   -->
    <net> 
      <value value="1050.00"/> 
      <currency value="USD"/>  
    </net>  
    <udi> 
      <reference value="#device-bridge"/> 
    </udi> 
    <bodySite> 
      <site> 
        <concept> 
          <coding> 
            <system value="http://fdi.org/fhir/oraltoothcodes"/> 
            <code value="01"/> 
          </coding> 
        </concept> 
      </site> 
    </bodySite> 
  </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"/> 
    <locationCodeableConcept> 
      <coding> 
        <system value="http://terminology.hl7.org/CodeSystem/ex-serviceplace"/> 
        <code value="11"/> 
      </coding> 
    </locationCodeableConcept> 
    <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"/> 
    <procedureSequence value="1"/> 
    <productOrService> 
      <coding> 
        <system value="http://example.org/fhir/oralservicecodes"/> 
        <code value="27211"/> 
      </coding> 
    </productOrService> 
    <servicedDate value="2014-08-16"/> 
    <locationCodeableConcept> 
      <coding> 
        <system value="http://terminology.hl7.org/CodeSystem/ex-serviceplace"/> 
        <code value="11"/> 
      </coding> 
    </locationCodeableConcept> 
    <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="24"/> 
          </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="1000.00"/> 
        <currency value="USD"/>  
      </unitPrice>  
      <factor value="0.75"/>    <!--   Student discount   -->
      <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> 
  <total> 
    <value value="2255.00"/> 
    <currency value="USD"/>  
  </total>  


</

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.