SOA Dental Claim (Contained) (id = "100152")

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


  
  
    
    
  

  
    
      
      
        
        
      
    
  

  
    
      
      
        
        
      
    
  

  
    
      
      
        
        
      
    
  

  
    
      
      
        
        
        
      
      
      
      
        
        
        
        
        
      
    
  

  
    
      

      
        
        
      

      

      
        
          
          
        
      

      
        
      

      
        
      
      

      
        
          
        
      

      
        
          
          
        
      

      
        
          
            
            
          
        
        
        
      

      
        
          
            
            
          
        
        
        
      

      
        
          
            
            
          
        
        
      

    
  

  
    
    
  

  

  
    
      
      
    
  

  

  
    
  

  

  
    
  

  
    
    

  
    
      
    
  

  
    
      
        
      
    
  

  
    
    
      
    
  

  
    
    
      
        
      
    
  

  
    
    
    
      
    
  

  
    
    
    
      
        
      
    
    
    
      
      
    
    
      
      
    
  

<Claim xmlns="http://hl7.org/fhir">
  <id value="100152"/> 
  <text> 
    <status value="generated"/> 
    <div xmlns="http://www.w3.org/1999/xhtml">A human-readable rendering of the Oral Health Claim</div> 
  </text> 
  <contained> 
    <Organization> 
      <id value="org-insurer"/> 
      <identifier> 
        <system value="http://www.bindb.com/bin"/> 
        <value value="123456"/> 
      </identifier> 
    </Organization> 
  </contained> 
  <contained> 
    <Organization> 
      <id value="org-org"/> 
      <identifier> 
        <system value="http://www.jurisdiction.com/oralhealthoffices"/> 
        <value value="3456"/> 
      </identifier> 
    </Organization> 
  </contained> 
  <contained> 
    <Practitioner> 
      <id value="provider-1"/> 
      <identifier> 
        <system value="http://www.jurisdiction.com/oralhealthproviders"/> 
        <value value="123456789"/> 
      </identifier> 
    </Practitioner> 
  </contained> 
  <contained> 
    <Patient> 
      <id value="patient-1"/> 
      <name> 
        <use value="official"/> 
        <family value="Donald"/> 
        <given value="Duck"/> 
      </name> 
      <gender value="male"/> 
      <birthDate value="1986-05-17"/> 
      <address> 
        <use value="home"/> 
        <line value="1234 Main Street"/> 
        <city value="Vancouver"/> 
        <postalCode value="V2H1Y3"/> 
        <country value="CAD"/> 
      </address> 
    </Patient> 
  </contained> 
  <contained> 
    <Coverage> 
      <id value="coverage-1"/> 
      <identifier> 
        <system value="http://benefitsinc.com/certificate"/> 
        <value value="12345"/> 
      </identifier> 
      <status value="active"/> 
      
      <kind value="insurance"/>       <type>         <coding>           <system value="http://terminology.hl7.org/CodeSystem/v3-ActCode"/>           <code value="EHCPOL"/>         </coding>       </type>       <subscriber>         <reference value="#patient-1"/>       </subscriber>       <beneficiary>         <reference value="#patient-1"/>       </beneficiary>       <dependent value="1"/>       <relationship>         <coding>           <code value="self"/>         </coding>       </relationship>       <insurer>         <identifier>           <system value="http://www.bindb.com/bin"/>           <value value="123456"/>         </identifier>       </insurer>       <class>         <type>           <coding>             <system value="http://terminology.hl7.org/CodeSystem/coverage-class"/>             <code value="plan"/>           </coding>         </type>         <value>           <value value="CBI35"/>         </value>         <name value="Corporate Baker's Inc. Plan#35"/>       </class>       <class>         <type>           <coding>             <system value="http://terminology.hl7.org/CodeSystem/coverage-class"/>             <code value="subplan"/>           </coding>         </type>         <value>           <value value="123"/>         </value>         <name value="Trainee Part-time Benefits"/>       </class>       <class>         <type>           <coding>             <system value="http://terminology.hl7.org/CodeSystem/coverage-class"/>             <code value="sequence"/>           </coding>         </type>         <value>           <value value="1"/>         </value>       </class>     </Coverage>   </contained>   <identifier>     <system value="http://happyvalley.com/claim"/>     <value value="12347"/>   </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="#org-insurer"/>   </insurer>   <provider>     <reference value="#org-org"/>   </provider>     <priority>     <coding>       <code value="normal"/>     </coding>   </priority>   <payee>     <type>       <coding>         <code value="provider"/>       </coding>     </type>   </payee>   <careTeam>     <sequence value="1"/>     <provider>       <reference value="#provider-1"/>     </provider>   </careTeam>   <diagnosis>     <sequence value="1"/>     <diagnosisCodeableConcept>       <coding>         <code value="123456"/>       </coding>     </diagnosisCodeableConcept>   </diagnosis>   <insurance>     <sequence value="1"/>     <focal value="true"/>     <coverage>       <reference value="#coverage-1"/>     </coverage>   </insurance>   <item>     <sequence value="1"/>     <careTeamSequence value="1"/>     <productOrService>       <coding>         <code value="1200"/>       </coding>     </productOrService>     <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

>