Claim-example-vision-glasses-3tier.xml

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Example Claim/660152 (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
Glasses Claim, 3 Tier, Secondary Coverage (id = "660152")
<?xml version="1.0" encoding="UTF-8"?>

<Claim xmlns="http://hl7.org/fhir">
  <id value="660152"/> 
  <text> 
    <status value="generated"/> <div xmlns="http://www.w3.org/1999/xhtml">A human-readable rendering of the Vision Claim for Glasses</div> 
  </text> 
  <!--   rest of the resource omitted for brevity   -->
  <contained> 
    <Device> 
      <id value="device-frame"/> 
    </Device> 
  </contained> 
  <!--   rest of the resource omitted for brevity   -->
  <contained> 
    <Device> 
      <id value="device-lens"/> 
    </Device> 
  </contained> 
  <identifier> 
    <system value="http://happysight.com/claim"/> 
    <value value="6612347"/> 
  </identifier> 
  <status value="active"/> 
  <type> 
    <coding> 
      <system value="http://terminology.hl7.org/CodeSystem/claim-type"/> 
      <code value="vision"/> 
    </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> 
  <prescription> 
    <reference value="http://www.optdocs.com/prescription/12345"/> 
  </prescription> 
  <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> 
        <code value="654321"/> 
      </coding> 
    </diagnosisCodeableConcept> 
  </diagnosis> 
  <insurance> 
    <!--   Patient's own coverage - primary   -->
    <sequence value="1"/> 
    <focal value="false"/> 
    <coverage> 
      <reference value="Coverage/9876B1"/> 
    </coverage> 
    <preAuthRef value="PR7652387237"/> 
    <claimResponse> 
      <reference value="ClaimResponse/R3500"/> 
    </claimResponse> 
  </insurance> 
  <insurance> 
    <!--   Spouses's own coverage - secondary   -->
    <sequence value="2"/> 
    <focal value="true"/> 
    <coverage> 
      <reference value="Coverage/9876B1"/> 
    </coverage> 
    <preAuthRef value="AB543GTD7567"/> 
  </insurance> 
  <item> 
    <sequence value="1"/> 
    <careTeamSequence value="1"/> 
    <revenue> 
      <coding> 
        <system value="http://terminology.hl7.org/CodeSystem/ex-revenue-center"/> 
        <code value="0010"/> 
        <display value="Vision Clinic"/> 
      </coding> 
    </revenue> 
    <category> 
      <coding> 
        <system value="http://example.org/fhir/CodeSystem/benefit-subcategory"/> 
        <code value="F6"/> 
        <display value="Vision Coverage"/> 
      </coding> 
    </category> 
    <productOrService> 
      <coding> 
        <system value="http://example.org/fhir/CodeSystem/ex-visionservice"/> 
        <code value="glasses"/> 
      </coding> 
    </productOrService> 
    <modifier> 
      <coding> 
        <system value="http://terminology.hl7.org/CodeSystem/modifiers"/> 
        <code value="rooh"/> 
      </coding> 
    </modifier> 
    <programCode> 
      <coding> 
        <system value="http://terminology.hl7.org/CodeSystem/ex-programcode"/> 
        <code value="none"/> 
      </coding> 
    </programCode> 
    <servicedDate value="2014-08-16"/> 
    <unitPrice> 
      <value value="235.40"/> 
      <currency value="USD"/> 
    </unitPrice> 
    <net> 
      <value value="235.40"/> 
      <currency value="USD"/> 
    </net> 
    <detail> 
      <sequence value="1"/> 
      <revenue> 
        <coding> 
          <system value="http://terminology.hl7.org/CodeSystem/ex-revenue-center"/> 
          <code value="0010"/> 
          <display value="Vision Clinic"/> 
        </coding> 
      </revenue> 
      <category> 
        <coding> 
          <system value="http://example.org/fhir/CodeSystem/benefit-subcategory"/> 
          <code value="F6"/> 
          <display value="Vision Coverage"/> 
        </coding> 
      </category> 
      <productOrService> 
        <coding> 
          <system value="http://example.org/fhir/CodeSystem/ex-visionservice"/> 
          <code value="frame"/> 
        </coding> 
      </productOrService> 
      <modifier> 
        <coding> 
          <system value="http://terminology.hl7.org/CodeSystem/modifiers"/> 
          <code value="rooh"/> 
        </coding> 
      </modifier> 
      <unitPrice> 
        <value value="100.00"/> 
        <currency value="USD"/> 
      </unitPrice> 
      <factor value="1.1"/> 
      <!--   10% surcharge for out of hours work   -->
      <net> 
        <value value="110.00"/> 
        <currency value="USD"/> 
      </net> 
      <udi> 
        <reference value="#device-frame"/> 
      </udi> 
    </detail> 
    <detail> 
      <sequence value="2"/> 
      <revenue> 
        <coding> 
          <system value="http://terminology.hl7.org/CodeSystem/ex-revenue-center"/> 
          <code value="0010"/> 
          <display value="Vision Clinic"/> 
        </coding> 
      </revenue> 
      <category> 
        <coding> 
          <system value="http://example.org/fhir/CodeSystem/benefit-subcategory"/> 
          <code value="F6"/> 
          <display value="Vision Coverage"/> 
        </coding> 
      </category> 
      <productOrService> 
        <coding> 
          <system value="http://example.org/fhir/CodeSystem/ex-visionservice"/> 
          <code value="lens"/> 
        </coding> 
      </productOrService> 
      <programCode> 
        <coding> 
          <system value="http://terminology.hl7.org/CodeSystem/ex-programcode"/> 
          <code value="none"/> 
        </coding> 
      </programCode> 
      <quantity> 
        <value value="2"/> 
      </quantity> 
      <unitPrice> 
        <value value="55.00"/> 
        <currency value="USD"/> 
      </unitPrice> 
      <net> 
        <value value="110.00"/> 
        <currency value="USD"/> 
      </net> 
      <subDetail> 
        <sequence value="1"/> 
        <revenue> 
          <coding> 
            <system value="http://terminology.hl7.org/CodeSystem/ex-revenue-center"/> 
            <code value="0010"/> 
            <display value="Vision Clinic"/> 
          </coding> 
        </revenue> 
        <category> 
          <coding> 
            <system value="http://example.org/fhir/CodeSystem/benefit-subcategory"/> 
            <code value="F6"/> 
            <display value="Vision Coverage"/> 
          </coding> 
        </category> 
        <productOrService> 
          <coding> 
            <system value="http://example.org/fhir/CodeSystem/ex-visionservice"/> 
            <code value="lens"/> 
          </coding> 
        </productOrService> 
        <modifier> 
          <coding> 
            <system value="http://terminology.hl7.org/CodeSystem/modifiers"/> 
            <code value="rooh"/> 
          </coding> 
        </modifier> 
        <programCode> 
          <coding> 
            <system value="http://terminology.hl7.org/CodeSystem/ex-programcode"/> 
            <code value="none"/> 
          </coding> 
        </programCode> 
        <quantity> 
          <value value="2"/> 
        </quantity> 
        <unitPrice> 
          <value value="30.00"/> 
          <currency value="USD"/> 
        </unitPrice> 
        <factor value="1.1"/> 
        <!--   10% surchage for out of hours work   -->
        <net> 
          <value value="66.00"/> 
          <currency value="USD"/> 
        </net> 
        <udi> 
          <reference value="#device-lens"/> 
        </udi> 
      </subDetail> 
      <subDetail> 
        <sequence value="2"/> 
        <revenue> 
          <coding> 
            <system value="http://terminology.hl7.org/CodeSystem/ex-revenue-center"/> 
            <code value="0010"/> 
            <display value="Vision Clinic"/> 
          </coding> 
        </revenue> 
        <category> 
          <coding> 
            <system value="http://example.org/fhir/CodeSystem/benefit-subcategory"/> 
            <code value="F6"/> 
            <display value="Vision Coverage"/> 
          </coding> 
        </category> 
        <productOrService> 
          <coding> 
            <system value="http://example.org/fhir/CodeSystem/ex-visionservice"/> 
            <code value="hardening"/> 
          </coding> 
        </productOrService> 
        <modifier> 
          <coding> 
            <system value="http://terminology.hl7.org/CodeSystem/modifiers"/> 
            <code value="rooh"/> 
          </coding> 
        </modifier> 
        <quantity> 
          <value value="2"/> 
        </quantity> 
        <unitPrice> 
          <value value="15.00"/> 
          <currency value="USD"/> 
        </unitPrice> 
        <factor value="1.1"/> 
        <!--   10% surchage for out of hours work   -->
        <net> 
          <value value="33.00"/> 
          <currency value="USD"/> 
        </net> 
      </subDetail> 
      <subDetail> 
        <sequence value="3"/> 
        <revenue> 
          <coding> 
            <system value="http://terminology.hl7.org/CodeSystem/ex-revenue-center"/> 
            <code value="0010"/> 
            <display value="Vision Clinic"/> 
          </coding> 
        </revenue> 
        <category> 
          <coding> 
            <system value="http://example.org/fhir/CodeSystem/benefit-subcategory"/> 
            <code value="F6"/> 
            <display value="Vision Coverage"/> 
          </coding> 
        </category> 
        <productOrService> 
          <coding> 
            <system value="http://example.org/fhir/CodeSystem/ex-visionservice"/> 
            <code value="UV coating"/> 
          </coding> 
        </productOrService> 
        <modifier> 
          <coding> 
            <system value="http://terminology.hl7.org/CodeSystem/modifiers"/> 
            <code value="rooh"/> 
          </coding> 
        </modifier> 
        <quantity> 
          <value value="2"/> 
        </quantity> 
        <unitPrice> 
          <value value="5.00"/> 
          <currency value="USD"/> 
        </unitPrice> 
        <factor value="1.1"/> 
        <!--   10% surchage for out of hours work   -->
        <net> 
          <value value="11.00"/> 
          <currency value="USD"/> 
        </net> 
      </subDetail> 
    </detail> 
    <detail> 
      <sequence value="3"/> 
      <revenue> 
        <coding> 
          <system value="http://terminology.hl7.org/CodeSystem/ex-revenue-center"/> 
          <code value="0010"/> 
          <display value="Vision Clinic"/> 
        </coding> 
      </revenue> 
      <category> 
        <coding> 
          <system value="http://example.org/fhir/CodeSystem/benefit-subcategory"/> 
          <code value="F6"/> 
          <display value="Vision Coverage"/> 
        </coding> 
      </category> 
      <productOrService> 
        <coding> 
          <system value="http://example.org/fhir/CodeSystem/ex-visionservice"/> 
          <code value="fst"/> 
        </coding> 
      </productOrService> 
      <unitPrice> 
        <value value="220.00"/> 
        <currency value="USD"/> 
      </unitPrice> 
      <factor value="0.07"/> 
      <net> 
        <value value="15.40"/> 
        <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.