Glasses Claim

{
  "resourceType" : "Claim",
  "id" : "660151",
  "text" : {
    "status" : "generated",
    "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\">A human-readable rendering of the Vision Claim for Glasses</div>"
  },
  "identifier" : [{
    "system" : "http://happysight.com/claim",
    "value" : "6612346"
  }],
  "status" : "active",
  "type" : {
    "coding" : [{
      "system" : "http://terminology.hl7.org/CodeSystem/claim-type",
      "code" : "vision"
    }]
  },
  "use" : "claim",
  "patient" : {
    "reference" : "Patient/1"
  },
  "created" : "2014-08-16",
  "insurer" : {
    "reference" : "Organization/2"
  },
  "provider" : {
    "reference" : "Organization/1"
  },
  "priority" : {
    "coding" : [{
      "code" : "normal"
    }]
  },
  "prescription" : {
    "reference" : "http://www.optdocs.com/prescription/12345"
  },
  "payee" : {
    "type" : {
      "coding" : [{
        "code" : "provider"
      }]
    }
  },
  "careTeam" : [{
    "sequence" : 1,
    "provider" : {
      "reference" : "Practitioner/example"
    }
  }],
  "diagnosis" : [{
    "sequence" : 1,
    "diagnosisCodeableConcept" : {
      "coding" : [{
        "code" : "654321"
      }]
    }
  }],
  "insurance" : [{
    "sequence" : 1,
    "focal" : true,
    "coverage" : {
      "reference" : "Coverage/9876B1"
    }
  }],
  "item" : [{
    "sequence" : 1,
    "careTeamSequence" : [1],
    "productOrService" : {
      "coding" : [{
        "system" : "http://example.org/fhir/CodeSystem/ex-visionservice",
        "code" : "glasses"
      }]
    },
    "servicedDate" : "2014-08-16",
    "unitPrice" : {
      "value" : 214.00,
      "currency" : "USD"
    },
    "net" : {
      "value" : 214.00,
      "currency" : "USD"
    },
    "detail" : [{
      "sequence" : 1,
      "productOrService" : {
        "coding" : [{
          "system" : "http://example.org/fhir/CodeSystem/ex-visionservice",
          "code" : "frame"
        }]
      },
      "unitPrice" : {
        "value" : 100.00,
        "currency" : "USD"
      },
      "net" : {
        "value" : 100.00,
        "currency" : "USD"
      }
    },
    {
      "sequence" : 2,
      "productOrService" : {
        "coding" : [{
          "system" : "http://example.org/fhir/CodeSystem/ex-visionservice",
          "code" : "lens"
        }]
      },
      "quantity" : {
        "value" : 2
      },
      "unitPrice" : {
        "value" : 50.00,
        "currency" : "USD"
      },
      "net" : {
        "value" : 100.00,
        "currency" : "USD"
      }
    },
    {
      "sequence" : 3,
      "productOrService" : {
        "coding" : [{
          "system" : "http://example.org/fhir/CodeSystem/ex-visionservice",
          "code" : "fst"
        }]
      },
      "unitPrice" : {
        "value" : 200.00,
        "currency" : "USD"
      },
      "factor" : 0.07,
      "net" : {
        "value" : 14.00,
        "currency" : "USD"
      }
    }]
  }]
}