<?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"/>
  <subject>
    <reference value="Patient/1"/>
  </subject>
  <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>
    <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>