Claim - FHIR v0.4.0

This page is part of the FHIR Specification (v0.0.82: DSTU 1). 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 R2

7.1.5 Resource Claim - Examples

7.1.5.1 General-Claim-Oral-Simple

Simple dental Claim (id = "100150")

Raw XML

<Claim xmlns="http://hl7.org/fhir">
  <id value="100150"/>
  <text>
    <status value="generated"/>
    <div xmlns="http://www.w3.org/1999/xhtml"><!-- Snipped for brevity --></div>
  </text>
  <type value="oral"/>
  <identifier>
    <system value="http://happyvalley.com/claim"/>
    <value value="12345"/>
  </identifier>
  <created value="2014-08-16"/>
  <target>
    <reference value="Organization/2"/>
  </target>
  <organization>
    <reference value="Organization/1"/>
  </organization>
  <use value="complete"/>
  <priority>
    <code value="normal"/>
  </priority>
  <payee>
    <type>
      <code value="provider"/>
    </type>
  </payee>
  <diagnosis>
    <sequence value="1"/>
    <diagnosis>
      <code value="123456"/>
    </diagnosis>
  </diagnosis>
  <patient>
    <reference value="Patient/1"/>
  </patient>
  <coverage>
    <sequence value="1"/>
    <focal value="true"/>
    <coverage>
      <reference value="Coverage/9876B1"/>
    </coverage>
    <relationship>
      <code value="self"/>
    </relationship>
  </coverage>
  <item>
    <sequence value="1"/>
    <type>
      <code value="service"/>
    </type>
    <provider>
      <reference value="Practitioner/1"/>
    </provider>
    <service>
      <code value="1200"/>
    </service>
    <serviceDate value="2014-08-16"/>
    <unitPrice>
      <value value="135.57"/>
      <system value="urn:std:iso:4217"/>
      <code value="USD"/>
    </unitPrice>
    <net>
      <value value="135.57"/>
      <system value="urn:std:iso:4217"/>
      <code value="USD"/>
    </net>
  </item>
</Claim>

Simple dental Claim

Raw JSON (Canonical)

{
  "resourceType": "Claim",
  "id": "100150",
  "text": {
    "status": "generated",
    "div": "<div>!-- Snipped for Brevity --></div>"
  },
  "type": "oral",
  "identifier": [
    {
      "system": "http://happyvalley.com/claim",
      "value": "12345"
    }
  ],
  "created": "2014-08-16",
  "target": {
    "reference": "Organization/2"
  },
  "organization": {
    "reference": "Organization/1"
  },
  "use": "complete",
  "priority": {
    "code": "normal"
  },
  "payee": {
    "type": {
      "code": "provider"
    }
  },
  "diagnosis": [
    {
      "sequence": 1,
      "diagnosis": {
        "code": "123456"
      }
    }
  ],
  "patient": {
    "reference": "Patient/1"
  },
  "coverage": [
    {
      "sequence": 1,
      "focal": true,
      "coverage": {
        "reference": "Coverage/9876B1"
      },
      "relationship": {
        "code": "self"
      }
    }
  ],
  "item": [
    {
      "sequence": 1,
      "type": {
        "code": "service"
      },
      "provider": {
        "reference": "Practitioner/1"
      },
      "service": {
        "code": "1200"
      },
      "serviceDate": "2014-08-16",
      "unitPrice": {
        "value": 135.57,
        "system": "urn:std:iso:4217",
        "code": "USD"
      },
      "net": {
        "value": 135.57,
        "system": "urn:std:iso:4217",
        "code": "USD"
      }
    }
  ]
}

7.1.5.2 General-Claim-Oral-Average

Average dental Claim (id = "100151")

Raw XML

<Claim xmlns="http://hl7.org/fhir">
  <id value="100151"/>
  <text>
    <status value="generated"/>
    <div xmlns="http://www.w3.org/1999/xhtml"><!-- Snipped for brevity --></div>
  </text>
  <type value="oral"/>
  <identifier>
    <system value="http://happyvalley.com/claim"/>
    <value value="12346"/>
  </identifier>
  <created value="2014-08-16"/>
  <target>
    <reference value="Organization/2"/>
  </target>
  <organization>
    <reference value="Organization/1"/>
  </organization>
  <use value="complete"/>
  <priority>
    <code value="normal"/>
  </priority>
  <payee>
    <type>
      <code value="provider"/>
    </type>
  </payee>
  <diagnosis>
    <sequence value="1"/>
    <diagnosis>
      <code value="123456"/>
    </diagnosis>
  </diagnosis>
  <patient>
    <reference value="Patient/1"/>
  </patient>
  <coverage>
    <sequence value="1"/>
    <focal value="true"/>
    <coverage>
      <reference value="Coverage/9876B1"/>
    </coverage>
    <relationship>
      <code value="self"/>
    </relationship>
  </coverage>
  <item>
    <sequence value="1"/>
    <type>
      <code value="service"/>
    </type>
    <provider>
      <reference value="Practitioner/1"/>
    </provider>
    <service>
      <system value="http://hl7.org/fhir/oralservicecodes"/>
      <code value="1200"/>
    </service>
    <serviceDate value="2014-08-16"/>
    <unitPrice>
      <value value="135.57"/>
      <system value="urn:std:iso:4217"/>
      <code value="USD"/>
    </unitPrice>
    <net>
      <value value="135.57"/>
      <system value="urn:std:iso:4217"/>
      <code value="USD"/>
    </net>
  </item>
  <item>
    <sequence value="2"/>
    <type>
      <code value="service"/>
    </type>
    <provider>
      <reference value="Practitioner/1"/>
    </provider>
    <service>
      <system value="http://hl7.org/fhir/oralservicecodes"/>
      <code value="21211"/>
    </service>
    <serviceDate value="2014-08-16"/>
    <unitPrice>
      <value value="105.00"/>
      <system value="urn:std:iso:4217"/>
      <code value="USD"/>
    </unitPrice>
    <net>
      <value value="105.00"/>
      <system value="urn:std:iso:4217"/>
      <code value="USD"/>
    </net>
    <bodySite>
      <system value="http://fdi.org/fhir/oraltoothcodes"/>
      <code value="21"/>
    </bodySite>
    <subSite>
      <system value="http://fdi.org/fhir/oralsurfacecodes"/>
      <code value="L"/>
    </subSite>
  </item>
  <item>
    <sequence value="3"/>
    <type>
      <code value="group"/>
    </type>
    <provider>
      <reference value="Practitioner/1"/>
    </provider>
    <service>
      <system value="http://hl7.org/fhir/oralservicecodes"/>
      <code value="27211"/>
    </service>
    <serviceDate value="2014-08-16"/>
    <unitPrice>
      <value value="1100.00"/>
      <system value="urn:std:iso:4217"/>
      <code value="USD"/>
    </unitPrice>
    <net>
      <value value="1100.00"/>
      <system value="urn:std:iso:4217"/>
      <code value="USD"/>
    </net>
    <bodySite>
      <system value="http://fdi.org/fhir/oraltoothcodes"/>
      <code value="36"/>
    </bodySite>
    <detail>
      <sequence value="1"/>
      <type>
        <code value="service"/>
      </type>
      <service>
        <system value="http://hl7.org/fhir/oralservicecodes"/>
        <code value="27211"/>
      </service>
      <unitPrice>
        <value value="750.00"/>
        <system value="urn:std:iso:4217"/>
        <code value="USD"/>
      </unitPrice>
      <net>
        <value value="750.00"/>
        <system value="urn:std:iso:4217"/>
        <code value="USD"/>
      </net>
    </detail>
    <detail>
      <sequence value="2"/>
      <type>
        <code value="service"/>
      </type>
      <service>
        <system value="http://hl7.org/fhir/oralservicecodes"/>
        <code value="lab"/>
      </service>
      <unitPrice>
        <value value="350.00"/>
        <system value="urn:std:iso:4217"/>
        <code value="USD"/>
      </unitPrice>
      <net>
        <value value="350.00"/>
        <system value="urn:std:iso:4217"/>
        <code value="USD"/>
      </net>
    </detail>
  </item>
</Claim>

Average dental Claim

Raw JSON (Canonical)

{
  "resourceType": "Claim",
  "id": "100151",
  "text": {
    "status": "generated",
    "div": "<div>!-- Snipped for Brevity --></div>"
  },
  "type": "oral",
  "identifier": [
    {
      "system": "http://happyvalley.com/claim",
      "value": "12346"
    }
  ],
  "created": "2014-08-16",
  "target": {
    "reference": "Organization/2"
  },
  "organization": {
    "reference": "Organization/1"
  },
  "use": "complete",
  "priority": {
    "code": "normal"
  },
  "payee": {
    "type": {
      "code": "provider"
    }
  },
  "diagnosis": [
    {
      "sequence": 1,
      "diagnosis": {
        "code": "123456"
      }
    }
  ],
  "patient": {
    "reference": "Patient/1"
  },
  "coverage": [
    {
      "sequence": 1,
      "focal": true,
      "coverage": {
        "reference": "Coverage/9876B1"
      },
      "relationship": {
        "code": "self"
      }
    }
  ],
  "item": [
    {
      "sequence": 1,
      "type": {
        "code": "service"
      },
      "provider": {
        "reference": "Practitioner/1"
      },
      "service": {
        "system": "http://hl7.org/fhir/oralservicecodes",
        "code": "1200"
      },
      "serviceDate": "2014-08-16",
      "unitPrice": {
        "value": 135.57,
        "system": "urn:std:iso:4217",
        "code": "USD"
      },
      "net": {
        "value": 135.57,
        "system": "urn:std:iso:4217",
        "code": "USD"
      }
    },
    {
      "sequence": 2,
      "type": {
        "code": "service"
      },
      "provider": {
        "reference": "Practitioner/1"
      },
      "service": {
        "system": "http://hl7.org/fhir/oralservicecodes",
        "code": "21211"
      },
      "serviceDate": "2014-08-16",
      "unitPrice": {
        "value": 105.00,
        "system": "urn:std:iso:4217",
        "code": "USD"
      },
      "net": {
        "value": 105.00,
        "system": "urn:std:iso:4217",
        "code": "USD"
      },
      "bodySite": {
        "system": "http://fdi.org/fhir/oraltoothcodes",
        "code": "21"
      },
      "subSite": [
        {
          "system": "http://fdi.org/fhir/oralsurfacecodes",
          "code": "L"
        }
      ]
    },
    {
      "sequence": 3,
      "type": {
        "code": "group"
      },
      "provider": {
        "reference": "Practitioner/1"
      },
      "service": {
        "system": "http://hl7.org/fhir/oralservicecodes",
        "code": "27211"
      },
      "serviceDate": "2014-08-16",
      "unitPrice": {
        "value": 1100.00,
        "system": "urn:std:iso:4217",
        "code": "USD"
      },
      "net": {
        "value": 1100.00,
        "system": "urn:std:iso:4217",
        "code": "USD"
      },
      "bodySite": {
        "system": "http://fdi.org/fhir/oraltoothcodes",
        "code": "36"
      },
      "detail": [
        {
          "sequence": 1,
          "type": {
            "code": "service"
          },
          "service": {
            "system": "http://hl7.org/fhir/oralservicecodes",
            "code": "27211"
          },
          "unitPrice": {
            "value": 750.00,
            "system": "urn:std:iso:4217",
            "code": "USD"
          },
          "net": {
            "value": 750.00,
            "system": "urn:std:iso:4217",
            "code": "USD"
          }
        },
        {
          "sequence": 2,
          "type": {
            "code": "service"
          },
          "service": {
            "system": "http://hl7.org/fhir/oralservicecodes",
            "code": "lab"
          },
          "unitPrice": {
            "value": 350.00,
            "system": "urn:std:iso:4217",
            "code": "USD"
          },
          "net": {
            "value": 350.00,
            "system": "urn:std:iso:4217",
            "code": "USD"
          }
        }
      ]
    }
  ]
}

7.1.5.3 General-Claim-Oral-Contained

SOA Dental Claim (id = "100152")

Raw XML

<Claim xmlns="http://hl7.org/fhir">
  <id value="100152"/>
  <text>
    <status value="generated"/>
    <div xmlns="http://www.w3.org/1999/xhtml"><!-- Snipped for brevity --></div>
  </text>
  <contained>
    <Organization>
      <id value="organization-1"/>
      <identifier>
        <system value="http://www.jurisdiction.com/oralhealthoffices"/>
        <value value="3456"/>
      </identifier>
    </Organization>
  </contained>
  <contained>
    <Organization>
      <id value="organization-2"/>
      <identifier>
        <system value="http://www.bindb.com/bin"/>
        <value value="123456"/>
      </identifier>
    </Organization>
  </contained>
  <contained>
    <Practitioner>
      <id value="practitioner-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"/>
      <issuer>
        <reference value="#organization-2"/>
      </issuer>
      <type>
        <system value="http://hl7.org/fhir/v3/ActCode"/>
        <code value="EHCPOL"/>
      </type>
      <identifier>
        <system value="http://benefitsinc.com/certificate"/>
        <value value="12345"/>
      </identifier>
      <plan value="CBI35"/>
      <subPlan value="123"/>
      <dependent value="0"/>
      <sequence value="1"/>
      <subscriber>
        <reference value="#patient-1"/>
      </subscriber>
    </Coverage>
  </contained>
  <type value="oral"/>
  <identifier>
    <system value="http://happyvalley.com/claim"/>
    <value value="12347"/>
  </identifier>
  <created value="2014-08-16"/>
  <target>
    <reference value="#organization-2"/>
  </target>
  <organization>
    <reference value="#organization-1"/>
  </organization>
  <use value="complete"/>
  <priority>
    <code value="normal"/>
  </priority>
  <payee>
    <type>
      <code value="provider"/>
    </type>
  </payee>
  <diagnosis>
    <sequence value="1"/>
    <diagnosis>
      <code value="123456"/>
    </diagnosis>
  </diagnosis>
  <patient>
    <reference value="#patient-1"/>
  </patient>
  <coverage>
    <sequence value="1"/>
    <focal value="true"/>
    <coverage>
      <reference value="#coverage-1"/>
    </coverage>
    <relationship>
      <code value="self"/>
    </relationship>
  </coverage>
  <item>
    <sequence value="1"/>
    <type>
      <code value="service"/>
    </type>
    <provider>
      <reference value="#practitioner-1"/>
    </provider>
    <service>
      <code value="1200"/>
    </service>
    <serviceDate value="2014-08-16"/>
    <unitPrice>
      <value value="135.57"/>
      <system value="urn:std:iso:4217"/>
      <code value="USD"/>
    </unitPrice>
    <net>
      <value value="135.57"/>
      <system value="urn:std:iso:4217"/>
      <code value="USD"/>
    </net>
  </item>
</Claim>

SOA Dental Claim

Raw JSON (Canonical)

{
  "resourceType": "Claim",
  "id": "100152",
  "text": {
    "status": "generated",
    "div": "<div>!-- Snipped for Brevity --></div>"
  },
  "contained": [
    {
      "resourceType": "Organization",
      "id": "organization-1",
      "identifier": [
        {
          "system": "http://www.jurisdiction.com/oralhealthoffices",
          "value": "3456"
        }
      ]
    },
    {
      "resourceType": "Organization",
      "id": "organization-2",
      "identifier": [
        {
          "system": "http://www.bindb.com/bin",
          "value": "123456"
        }
      ]
    },
    {
      "resourceType": "Practitioner",
      "id": "practitioner-1",
      "identifier": [
        {
          "system": "http://www.jurisdiction.com/oralhealthproviders",
          "value": "123456789"
        }
      ]
    },
    {
      "resourceType": "Patient",
      "id": "patient-1",
      "name": [
        {
          "use": "official",
          "family": [
            "Donald"
          ],
          "given": [
            "Duck"
          ]
        }
      ],
      "gender": "male",
      "birthDate": "1986-05-17",
      "address": [
        {
          "use": "home",
          "line": [
            "1234 Main Street"
          ],
          "city": "Vancouver",
          "postalCode": "V2H1Y3",
          "country": "CAD"
        }
      ]
    },
    {
      "resourceType": "Coverage",
      "id": "coverage-1",
      "issuer": {
        "reference": "#organization-2"
      },
      "type": {
        "system": "http://hl7.org/fhir/v3/ActCode",
        "code": "EHCPOL"
      },
      "identifier": [
        {
          "system": "http://benefitsinc.com/certificate",
          "value": "12345"
        }
      ],
      "plan": "CBI35",
      "subPlan": "123",
      "dependent": 0,
      "sequence": 1,
      "subscriber": {
        "reference": "#patient-1"
      }
    }
  ],
  "type": "oral",
  "identifier": [
    {
      "system": "http://happyvalley.com/claim",
      "value": "12347"
    }
  ],
  "created": "2014-08-16",
  "target": {
    "reference": "#organization-2"
  },
  "organization": {
    "reference": "#organization-1"
  },
  "use": "complete",
  "priority": {
    "code": "normal"
  },
  "payee": {
    "type": {
      "code": "provider"
    }
  },
  "diagnosis": [
    {
      "sequence": 1,
      "diagnosis": {
        "code": "123456"
      }
    }
  ],
  "patient": {
    "reference": "#patient-1"
  },
  "coverage": [
    {
      "sequence": 1,
      "focal": true,
      "coverage": {
        "reference": "#coverage-1"
      },
      "relationship": {
        "code": "self"
      }
    }
  ],
  "item": [
    {
      "sequence": 1,
      "type": {
        "code": "service"
      },
      "provider": {
        "reference": "#practitioner-1"
      },
      "service": {
        "code": "1200"
      },
      "serviceDate": "2014-08-16",
      "unitPrice": {
        "value": 135.57,
        "system": "urn:std:iso:4217",
        "code": "USD"
      },
      "net": {
        "value": 135.57,
        "system": "urn:std:iso:4217",
        "code": "USD"
      }
    }
  ]
}

7.1.5.4 General-PreAuth-Oral-OthoPlan

PreAuthorization with Orthodontic Treatment Plan (id = "100153")

Raw XML

<Claim xmlns="http://hl7.org/fhir">
  <id value="100153"/>
  <text>
    <status value="generated"/>
    <div xmlns="http://www.w3.org/1999/xhtml"><!-- Snipped for brevity --></div>
  </text>
  <type value="oral"/>
  <identifier>
    <system value="http://happyvalley.com/claim"/>
    <value value="12355"/>
  </identifier>
  <created value="2015-03-16"/>
  <target>
    <reference value="Organization/2"/>
  </target>
  <organization>
    <reference value="Organization/1"/>
  </organization>
  <use value="proposed"/>
  <priority>
    <code value="normal"/>
  </priority>
  <payee>
    <type>
      <code value="provider"/>
    </type>
  </payee>
  <diagnosis>
    <sequence value="1"/>
    <diagnosis>
      <system value="http://hl7.org/fhir/icd-10"/>
      <code value="123457"/>
    </diagnosis>
  </diagnosis>
  <patient>
    <reference value="Patient/1"/>
  </patient>
  <coverage>
    <sequence value="1"/>
    <focal value="true"/>
    <coverage>
      <reference value="Coverage/9876B1"/>
    </coverage>
    <relationship>
      <code value="self"/>
    </relationship>
  </coverage>
  <item>
    <sequence value="1"/>
    <type>
      <system value="http://hl7.org/fhir/actinvoicegroupcode"/>
      <code value="group"/>
    </type>
    <provider>
      <reference value="Practitioner/1"/>
    </provider>
    <diagnosisLinkId value="1"/>
    <service>
      <system value="http://hl7.org/fhir/oralservicecodes"/>
      <code value="ORTHPLAN"/>
    </service>
    <serviceDate value="2015-05-16"/><!--    Start Date    -->
    <unitPrice>
      <value value="9000.00"/>
      <system value="urn:std:iso:4217"/>
      <code value="USD"/>
    </unitPrice>
    <net>
      <value value="9000.00"/>
      <system value="urn:std:iso:4217"/>
      <code value="USD"/>
    </net>
    <detail>
      <sequence value="1"/><!--    Exam Fee    -->
      <type>
        <system value="http://hl7.org/fhir/actinvoicegroupcode"/>
        <code value="service"/>
      </type>
      <service>
        <system value="http://hl7.org/fhir/oralservicecodes"/>
        <code value="ORTHOEXAM"/>
      </service>
      <unitPrice>
        <value value="1000.00"/>
        <system value="urn:std:iso:4217"/>
        <code value="USD"/>
      </unitPrice>
      <net>
        <value value="1000.00"/>
        <system value="urn:std:iso:4217"/>
        <code value="USD"/>
      </net>
    </detail>
    <detail>
      <sequence value="2"/><!--    Diagnostic Fee    -->
      <type>
        <system value="http://hl7.org/fhir/actinvoicegroupcode"/>
        <code value="service"/>
      </type>
      <service>
        <system value="http://hl7.org/fhir/oralservicecodes"/>
        <code value="ORTHODIAG"/>
      </service>
      <unitPrice>
        <value value="1500.00"/>
        <system value="urn:std:iso:4217"/>
        <code value="USD"/>
      </unitPrice>
      <net>
        <value value="1500.00"/>
        <system value="urn:std:iso:4217"/>
        <code value="USD"/>
      </net>
    </detail>
    <detail>
      <sequence value="3"/><!--    Initial Payment    -->
      <type>
        <system value="http://hl7.org/fhir/actinvoicegroupcode"/>
        <code value="service"/>
      </type>
      <service>
        <system value="http://hl7.org/fhir/oralservicecodes"/>
        <code value="ORTHOINITIAL"/>
      </service>
      <unitPrice>
        <value value="500.00"/>
        <system value="urn:std:iso:4217"/>
        <code value="USD"/>
      </unitPrice>
      <net>
        <value value="500.00"/>
        <system value="urn:std:iso:4217"/>
        <code value="USD"/>
      </net>
    </detail>
    <detail>
      <sequence value="4"/><!--    Duration in Months    -->
      <type>
        <system value="http://hl7.org/fhir/actinvoicegroupcode"/>
        <code value="service"/>
      </type>
      <service>
        <system value="http://hl7.org/fhir/oralservicecodes"/>
        <code value="ORTHOMONTHS"/>
      </service>
      <quantity>
        <value value="24"/>
      </quantity>
    </detail>
    <detail>
      <sequence value="5"/><!--    Periodic Payments    -->
      <type>
        <system value="http://hl7.org/fhir/actinvoicegroupcode"/>
        <code value="service"/>
      </type>
      <service>
        <system value="http://hl7.org/fhir/oralservicecodes"/>
        <code value="ORTHOPERIODIC"/>
      </service>
      <quantity>
        <value value="24"/>
      </quantity>
      <unitPrice>
        <value value="250.00"/>
        <system value="urn:std:iso:4217"/>
        <code value="USD"/>
      </unitPrice>
      <net>
        <value value="250.00"/>
        <system value="urn:std:iso:4217"/>
        <code value="USD"/>
      </net>
    </detail>
  </item>
  <item>
    <sequence value="2"/>
    <type>
      <code value="service"/>
    </type>
    <provider>
      <reference value="Practitioner/1"/>
    </provider>
    <service>
      <system value="http://hl7.org/fhir/oralservicecodes"/>
      <code value="21211"/>
    </service>
    <serviceDate value="2014-08-16"/>
    <unitPrice>
      <value value="105.00"/>
      <system value="urn:std:iso:4217"/>
      <code value="USD"/>
    </unitPrice>
    <net>
      <value value="105.00"/>
      <system value="urn:std:iso:4217"/>
      <code value="USD"/>
    </net>
    <bodySite>
      <system value="http://fdi.org/fhir/oraltoothcodes"/>
      <code value="21"/>
    </bodySite>
    <subSite>
      <system value="http://fdi.org/fhir/oralsurfacecodes"/>
      <code value="L"/>
    </subSite>
  </item>
  <item>
    <sequence value="3"/>
    <type>
      <code value="group"/>
    </type>
    <provider>
      <reference value="Practitioner/1"/>
    </provider>
    <service>
      <system value="http://hl7.org/fhir/oralservicecodes"/>
      <code value="27211"/>
    </service>
    <serviceDate value="2014-08-16"/>
    <unitPrice>
      <value value="1100.00"/>
      <system value="urn:std:iso:4217"/>
      <code value="USD"/>
    </unitPrice>
    <net>
      <value value="1100.00"/>
      <system value="urn:std:iso:4217"/>
      <code value="USD"/>
    </net>
    <bodySite>
      <system value="http://fdi.org/fhir/oraltoothcodes"/>
      <code value="36"/>
    </bodySite>
    <detail>
      <sequence value="1"/>
      <type>
        <code value="service"/>
      </type>
      <service>
        <system value="http://hl7.org/fhir/oralservicecodes"/>
        <code value="27211"/>
      </service>
      <unitPrice>
        <value value="750.00"/>
        <system value="urn:std:iso:4217"/>
        <code value="USD"/>
      </unitPrice>
      <net>
        <value value="750.00"/>
        <system value="urn:std:iso:4217"/>
        <code value="USD"/>
      </net>
    </detail>
    <detail>
      <sequence value="2"/>
      <type>
        <code value="service"/>
      </type>
      <service>
        <system value="http://hl7.org/fhir/oralservicecodes"/>
        <code value="lab"/>
      </service>
      <unitPrice>
        <value value="350.00"/>
        <system value="urn:std:iso:4217"/>
        <code value="USD"/>
      </unitPrice>
      <net>
        <value value="350.00"/>
        <system value="urn:std:iso:4217"/>
        <code value="USD"/>
      </net>
    </detail>
  </item>
</Claim>

PreAuthorization with Orthodontic Treatment Plan

Raw JSON (Canonical)

{
  "resourceType": "Claim",
  "id": "100153",
  "text": {
    "status": "generated",
    "div": "<div>!-- Snipped for Brevity --></div>"
  },
  "type": "oral",
  "identifier": [
    {
      "system": "http://happyvalley.com/claim",
      "value": "12355"
    }
  ],
  "created": "2015-03-16",
  "target": {
    "reference": "Organization/2"
  },
  "organization": {
    "reference": "Organization/1"
  },
  "use": "proposed",
  "priority": {
    "code": "normal"
  },
  "payee": {
    "type": {
      "code": "provider"
    }
  },
  "diagnosis": [
    {
      "sequence": 1,
      "diagnosis": {
        "system": "http://hl7.org/fhir/icd-10",
        "code": "123457"
      }
    }
  ],
  "patient": {
    "reference": "Patient/1"
  },
  "coverage": [
    {
      "sequence": 1,
      "focal": true,
      "coverage": {
        "reference": "Coverage/9876B1"
      },
      "relationship": {
        "code": "self"
      }
    }
  ],
  "item": [
    {
      "sequence": 1,
      "type": {
        "system": "http://hl7.org/fhir/actinvoicegroupcode",
        "code": "group"
      },
      "provider": {
        "reference": "Practitioner/1"
      },
      "diagnosisLinkId": [
        1
      ],
      "service": {
        "system": "http://hl7.org/fhir/oralservicecodes",
        "code": "ORTHPLAN"
      },
      "serviceDate": "2015-05-16",
      "unitPrice": {
        "value": 9000.00,
        "system": "urn:std:iso:4217",
        "code": "USD"
      },
      "net": {
        "value": 9000.00,
        "system": "urn:std:iso:4217",
        "code": "USD"
      },
      "detail": [
        {
          "sequence": 1,
          "type": {
            "system": "http://hl7.org/fhir/actinvoicegroupcode",
            "code": "service"
          },
          "service": {
            "system": "http://hl7.org/fhir/oralservicecodes",
            "code": "ORTHOEXAM"
          },
          "unitPrice": {
            "value": 1000.00,
            "system": "urn:std:iso:4217",
            "code": "USD"
          },
          "net": {
            "value": 1000.00,
            "system": "urn:std:iso:4217",
            "code": "USD"
          }
        },
        {
          "sequence": 2,
          "type": {
            "system": "http://hl7.org/fhir/actinvoicegroupcode",
            "code": "service"
          },
          "service": {
            "system": "http://hl7.org/fhir/oralservicecodes",
            "code": "ORTHODIAG"
          },
          "unitPrice": {
            "value": 1500.00,
            "system": "urn:std:iso:4217",
            "code": "USD"
          },
          "net": {
            "value": 1500.00,
            "system": "urn:std:iso:4217",
            "code": "USD"
          }
        },
        {
          "sequence": 3,
          "type": {
            "system": "http://hl7.org/fhir/actinvoicegroupcode",
            "code": "service"
          },
          "service": {
            "system": "http://hl7.org/fhir/oralservicecodes",
            "code": "ORTHOINITIAL"
          },
          "unitPrice": {
            "value": 500.00,
            "system": "urn:std:iso:4217",
            "code": "USD"
          },
          "net": {
            "value": 500.00,
            "system": "urn:std:iso:4217",
            "code": "USD"
          }
        },
        {
          "sequence": 4,
          "type": {
            "system": "http://hl7.org/fhir/actinvoicegroupcode",
            "code": "service"
          },
          "service": {
            "system": "http://hl7.org/fhir/oralservicecodes",
            "code": "ORTHOMONTHS"
          },
          "quantity": {
            "value": 24
          }
        },
        {
          "sequence": 5,
          "type": {
            "system": "http://hl7.org/fhir/actinvoicegroupcode",
            "code": "service"
          },
          "service": {
            "system": "http://hl7.org/fhir/oralservicecodes",
            "code": "ORTHOPERIODIC"
          },
          "quantity": {
            "value": 24
          },
          "unitPrice": {
            "value": 250.00,
            "system": "urn:std:iso:4217",
            "code": "USD"
          },
          "net": {
            "value": 250.00,
            "system": "urn:std:iso:4217",
            "code": "USD"
          }
        }
      ]
    },
    {
      "sequence": 2,
      "type": {
        "code": "service"
      },
      "provider": {
        "reference": "Practitioner/1"
      },
      "service": {
        "system": "http://hl7.org/fhir/oralservicecodes",
        "code": "21211"
      },
      "serviceDate": "2014-08-16",
      "unitPrice": {
        "value": 105.00,
        "system": "urn:std:iso:4217",
        "code": "USD"
      },
      "net": {
        "value": 105.00,
        "system": "urn:std:iso:4217",
        "code": "USD"
      },
      "bodySite": {
        "system": "http://fdi.org/fhir/oraltoothcodes",
        "code": "21"
      },
      "subSite": [
        {
          "system": "http://fdi.org/fhir/oralsurfacecodes",
          "code": "L"
        }
      ]
    },
    {
      "sequence": 3,
      "type": {
        "code": "group"
      },
      "provider": {
        "reference": "Practitioner/1"
      },
      "service": {
        "system": "http://hl7.org/fhir/oralservicecodes",
        "code": "27211"
      },
      "serviceDate": "2014-08-16",
      "unitPrice": {
        "value": 1100.00,
        "system": "urn:std:iso:4217",
        "code": "USD"
      },
      "net": {
        "value": 1100.00,
        "system": "urn:std:iso:4217",
        "code": "USD"
      },
      "bodySite": {
        "system": "http://fdi.org/fhir/oraltoothcodes",
        "code": "36"
      },
      "detail": [
        {
          "sequence": 1,
          "type": {
            "code": "service"
          },
          "service": {
            "system": "http://hl7.org/fhir/oralservicecodes",
            "code": "27211"
          },
          "unitPrice": {
            "value": 750.00,
            "system": "urn:std:iso:4217",
            "code": "USD"
          },
          "net": {
            "value": 750.00,
            "system": "urn:std:iso:4217",
            "code": "USD"
          }
        },
        {
          "sequence": 2,
          "type": {
            "code": "service"
          },
          "service": {
            "system": "http://hl7.org/fhir/oralservicecodes",
            "code": "lab"
          },
          "unitPrice": {
            "value": 350.00,
            "system": "urn:std:iso:4217",
            "code": "USD"
          },
          "net": {
            "value": 350.00,
            "system": "urn:std:iso:4217",
            "code": "USD"
          }
        }
      ]
    }
  ]
}

7.1.5.5 General-Claim-Vision-Exam

Simple Vision Claim (id = "660150")

Raw XML

<Claim xmlns="http://hl7.org/fhir">
  <id value="660150"/>
  <text>
    <status value="generated"/>
    <div xmlns="http://www.w3.org/1999/xhtml"><!-- Snipped for brevity --></div>
  </text>
  <type value="vision"/>
  <identifier>
    <system value="http://happysight.com/claim"/>
    <value value="6612345"/>
  </identifier>
  <created value="2014-08-16"/>
  <target>
    <reference value="Organization/2"/>
  </target>
  <organization>
    <reference value="Organization/1"/>
  </organization>
  <use value="complete"/>
  <priority>
    <code value="normal"/>
  </priority>
  <payee>
    <type>
      <code value="provider"/>
    </type>
  </payee>
  <diagnosis>
    <sequence value="1"/>
    <diagnosis>
      <code value="654321"/>
    </diagnosis>
  </diagnosis>
  <patient>
    <reference value="Patient/1"/>
  </patient>
  <coverage>
    <sequence value="1"/>
    <focal value="true"/>
    <coverage>
      <reference value="Coverage/9876B1"/>
    </coverage>
    <relationship>
      <code value="self"/>
    </relationship>
  </coverage>
  <item>
    <sequence value="1"/>
    <type>
      <code value="service"/>
    </type>
    <provider>
      <reference value="Practitioner/1"/>
    </provider>
    <service>
      <system value="http://hl7.org/fhir/ex-visionservice"/>
      <code value="exam"/>
    </service>
    <serviceDate value="2014-08-16"/>
    <unitPrice>
      <value value="80.00"/>
      <system value="urn:std:iso:4217"/>
      <code value="USD"/>
    </unitPrice>
    <net>
      <value value="80.00"/>
      <system value="urn:std:iso:4217"/>
      <code value="USD"/>
    </net>
  </item>
</Claim>

Simple Vision Claim

Raw JSON (Canonical)

{
  "resourceType": "Claim",
  "id": "660150",
  "text": {
    "status": "generated",
    "div": "<div>!-- Snipped for Brevity --></div>"
  },
  "type": "vision",
  "identifier": [
    {
      "system": "http://happysight.com/claim",
      "value": "6612345"
    }
  ],
  "created": "2014-08-16",
  "target": {
    "reference": "Organization/2"
  },
  "organization": {
    "reference": "Organization/1"
  },
  "use": "complete",
  "priority": {
    "code": "normal"
  },
  "payee": {
    "type": {
      "code": "provider"
    }
  },
  "diagnosis": [
    {
      "sequence": 1,
      "diagnosis": {
        "code": "654321"
      }
    }
  ],
  "patient": {
    "reference": "Patient/1"
  },
  "coverage": [
    {
      "sequence": 1,
      "focal": true,
      "coverage": {
        "reference": "Coverage/9876B1"
      },
      "relationship": {
        "code": "self"
      }
    }
  ],
  "item": [
    {
      "sequence": 1,
      "type": {
        "code": "service"
      },
      "provider": {
        "reference": "Practitioner/1"
      },
      "service": {
        "system": "http://hl7.org/fhir/ex-visionservice",
        "code": "exam"
      },
      "serviceDate": "2014-08-16",
      "unitPrice": {
        "value": 80.00,
        "system": "urn:std:iso:4217",
        "code": "USD"
      },
      "net": {
        "value": 80.00,
        "system": "urn:std:iso:4217",
        "code": "USD"
      }
    }
  ]
}

7.1.5.6 General-Claim-Institutional-Simple

Simple Institutional Service Claim (id = "960150")

Raw XML

<Claim xmlns="http://hl7.org/fhir">
  <id value="960150"/>
  <text>
    <status value="generated"/>
    <div xmlns="http://www.w3.org/1999/xhtml"><!-- Snipped for brevity --></div>
  </text>
  <type value="institutional"/>
  <identifier>
    <system value="http://happyhospital.com/claim"/>
    <value value="9612345"/>
  </identifier>
  <created value="2014-08-16"/>
  <target>
    <reference value="Organization/2"/>
  </target>
  <organization>
    <reference value="Organization/1"/>
  </organization>
  <use value="complete"/>
  <priority>
    <code value="normal"/>
  </priority>
  <payee>
    <type>
      <code value="provider"/>
    </type>
  </payee>
  <diagnosis>
    <sequence value="1"/>
    <diagnosis>
      <code value="654456"/>
    </diagnosis>
  </diagnosis>
  <patient>
    <reference value="Patient/1"/>
  </patient>
  <coverage>
    <sequence value="1"/>
    <focal value="true"/>
    <coverage>
      <reference value="Coverage/9876B1"/>
    </coverage>
    <relationship>
      <code value="self"/>
    </relationship>
  </coverage>
  <item>
    <sequence value="1"/>
    <type>
      <code value="service"/>
    </type>
    <provider>
      <reference value="Practitioner/1"/>
    </provider>
    <service>
      <system value="http://hl7.org/fhir/ex-serviceproduct"/>
      <code value="exam"/>
    </service>
    <serviceDate value="2014-08-16"/>
    <unitPrice>
      <value value="125.00"/>
      <system value="urn:std:iso:4217"/>
      <code value="USD"/>
    </unitPrice>
    <net>
      <value value="125.00"/>
      <system value="urn:std:iso:4217"/>
      <code value="USD"/>
    </net>
  </item>
</Claim>

Simple Institutional Service Claim

Raw JSON (Canonical)

{
  "resourceType": "Claim",
  "id": "960150",
  "text": {
    "status": "generated",
    "div": "<div>!-- Snipped for Brevity --></div>"
  },
  "type": "institutional",
  "identifier": [
    {
      "system": "http://happyhospital.com/claim",
      "value": "9612345"
    }
  ],
  "created": "2014-08-16",
  "target": {
    "reference": "Organization/2"
  },
  "organization": {
    "reference": "Organization/1"
  },
  "use": "complete",
  "priority": {
    "code": "normal"
  },
  "payee": {
    "type": {
      "code": "provider"
    }
  },
  "diagnosis": [
    {
      "sequence": 1,
      "diagnosis": {
        "code": "654456"
      }
    }
  ],
  "patient": {
    "reference": "Patient/1"
  },
  "coverage": [
    {
      "sequence": 1,
      "focal": true,
      "coverage": {
        "reference": "Coverage/9876B1"
      },
      "relationship": {
        "code": "self"
      }
    }
  ],
  "item": [
    {
      "sequence": 1,
      "type": {
        "code": "service"
      },
      "provider": {
        "reference": "Practitioner/1"
      },
      "service": {
        "system": "http://hl7.org/fhir/ex-serviceproduct",
        "code": "exam"
      },
      "serviceDate": "2014-08-16",
      "unitPrice": {
        "value": 125.00,
        "system": "urn:std:iso:4217",
        "code": "USD"
      },
      "net": {
        "value": 125.00,
        "system": "urn:std:iso:4217",
        "code": "USD"
      }
    }
  ]
}

7.1.5.7 General-Claim-Professional-Simple

Simple Pharmacy Service Claim (id = "860150")

Raw XML

<Claim xmlns="http://hl7.org/fhir">
  <id value="860150"/>
  <text>
    <status value="generated"/>
    <div xmlns="http://www.w3.org/1999/xhtml"><!-- Snipped for brevity --></div>
  </text>
  <type value="professional"/>
  <identifier>
    <system value="http://happypdocs.com/claim"/>
    <value value="8612345"/>
  </identifier>
  <created value="2014-08-16"/>
  <target>
    <reference value="Organization/2"/>
  </target>
  <organization>
    <reference value="Organization/1"/>
  </organization>
  <use value="complete"/>
  <priority>
    <code value="normal"/>
  </priority>
  <payee>
    <type>
      <code value="provider"/>
    </type>
  </payee>
  <diagnosis>
    <sequence value="1"/>
    <diagnosis>
      <code value="654456"/>
    </diagnosis>
  </diagnosis>
  <patient>
    <reference value="Patient/1"/>
  </patient>
  <coverage>
    <sequence value="1"/>
    <focal value="true"/>
    <coverage>
      <reference value="Coverage/9876B1"/>
    </coverage>
    <relationship>
      <code value="self"/>
    </relationship>
  </coverage>
  <item>
    <sequence value="1"/>
    <type>
      <code value="service"/>
    </type>
    <provider>
      <reference value="Practitioner/1"/>
    </provider>
    <service>
      <system value="http://hl7.org/fhir/ex-serviceproduct"/>
      <code value="exam"/>
    </service>
    <serviceDate value="2014-08-16"/>
    <unitPrice>
      <value value="75.00"/>
      <system value="urn:std:iso:4217"/>
      <code value="USD"/>
    </unitPrice>
    <net>
      <value value="75.00"/>
      <system value="urn:std:iso:4217"/>
      <code value="USD"/>
    </net>
  </item>
</Claim>

Simple Pharmacy Service Claim

Raw JSON (Canonical)

{
  "resourceType": "Claim",
  "id": "860150",
  "text": {
    "status": "generated",
    "div": "<div>!-- Snipped for Brevity --></div>"
  },
  "type": "professional",
  "identifier": [
    {
      "system": "http://happypdocs.com/claim",
      "value": "8612345"
    }
  ],
  "created": "2014-08-16",
  "target": {
    "reference": "Organization/2"
  },
  "organization": {
    "reference": "Organization/1"
  },
  "use": "complete",
  "priority": {
    "code": "normal"
  },
  "payee": {
    "type": {
      "code": "provider"
    }
  },
  "diagnosis": [
    {
      "sequence": 1,
      "diagnosis": {
        "code": "654456"
      }
    }
  ],
  "patient": {
    "reference": "Patient/1"
  },
  "coverage": [
    {
      "sequence": 1,
      "focal": true,
      "coverage": {
        "reference": "Coverage/9876B1"
      },
      "relationship": {
        "code": "self"
      }
    }
  ],
  "item": [
    {
      "sequence": 1,
      "type": {
        "code": "service"
      },
      "provider": {
        "reference": "Practitioner/1"
      },
      "service": {
        "system": "http://hl7.org/fhir/ex-serviceproduct",
        "code": "exam"
      },
      "serviceDate": "2014-08-16",
      "unitPrice": {
        "value": 75.00,
        "system": "urn:std:iso:4217",
        "code": "USD"
      },
      "net": {
        "value": 75.00,
        "system": "urn:std:iso:4217",
        "code": "USD"
      }
    }
  ]
}

7.1.5.8 General-Claim-Pharmacy-Simple

Simple Pharmacy Service Claim (id = "760150")

Raw XML

<Claim xmlns="http://hl7.org/fhir">
  <id value="760150"/>
  <text>
    <status value="generated"/>
    <div xmlns="http://www.w3.org/1999/xhtml"><!-- Snipped for brevity --></div>
  </text>
  <type value="pharmacy"/>
  <identifier>
    <system value="http://happypharma.com/claim"/>
    <value value="7612345"/>
  </identifier>
  <created value="2014-08-16"/>
  <target>
    <reference value="Organization/2"/>
  </target>
  <organization>
    <reference value="Organization/1"/>
  </organization>
  <use value="complete"/>
  <priority>
    <code value="stat"/>
  </priority>
  <payee>
    <type>
      <code value="provider"/>
    </type>
  </payee>
  <diagnosis>
    <sequence value="1"/>
    <diagnosis>
      <code value="654456"/>
    </diagnosis>
  </diagnosis>
  <patient>
    <reference value="Patient/1"/>
  </patient>
  <coverage>
    <sequence value="1"/>
    <focal value="true"/>
    <coverage>
      <reference value="Coverage/9876B1"/>
    </coverage>
    <relationship>
      <code value="self"/>
    </relationship>
  </coverage>
  <item>
    <sequence value="1"/>
    <type>
      <code value="service"/>
    </type>
    <provider>
      <reference value="Practitioner/1"/>
    </provider>
    <service>
      <system value="http://hl7.org/fhir/ex-pharmaservice"/>
      <code value="smokecess"/>
    </service><!--    smoking cessation consult    -->
    <serviceDate value="2014-08-16"/>
    <unitPrice>
      <value value="60.00"/>
      <system value="urn:std:iso:4217"/>
      <code value="USD"/>
    </unitPrice>
    <net>
      <value value="60.00"/>
      <system value="urn:std:iso:4217"/>
      <code value="USD"/>
    </net>
  </item>
</Claim>

Simple Pharmacy Service Claim

Raw JSON (Canonical)

{
  "resourceType": "Claim",
  "id": "760150",
  "text": {
    "status": "generated",
    "div": "<div>!-- Snipped for Brevity --></div>"
  },
  "type": "pharmacy",
  "identifier": [
    {
      "system": "http://happypharma.com/claim",
      "value": "7612345"
    }
  ],
  "created": "2014-08-16",
  "target": {
    "reference": "Organization/2"
  },
  "organization": {
    "reference": "Organization/1"
  },
  "use": "complete",
  "priority": {
    "code": "stat"
  },
  "payee": {
    "type": {
      "code": "provider"
    }
  },
  "diagnosis": [
    {
      "sequence": 1,
      "diagnosis": {
        "code": "654456"
      }
    }
  ],
  "patient": {
    "reference": "Patient/1"
  },
  "coverage": [
    {
      "sequence": 1,
      "focal": true,
      "coverage": {
        "reference": "Coverage/9876B1"
      },
      "relationship": {
        "code": "self"
      }
    }
  ],
  "item": [
    {
      "sequence": 1,
      "type": {
        "code": "service"
      },
      "provider": {
        "reference": "Practitioner/1"
      },
      "service": {
        "system": "http://hl7.org/fhir/ex-pharmaservice",
        "code": "smokecess"
      },
      "serviceDate": "2014-08-16",
      "unitPrice": {
        "value": 60.00,
        "system": "urn:std:iso:4217",
        "code": "USD"
      },
      "net": {
        "value": 60.00,
        "system": "urn:std:iso:4217",
        "code": "USD"
      }
    }
  ]
}

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.

Simple dental Claim	XML	JSON
Average dental Claim	XML	JSON
SOA Dental Claim	XML	JSON
PreAuthorization with Orthodontic Treatment Plan	XML	JSON
Simple Vision Claim	XML	JSON
Glasses Claim	XML	JSON
Simple Institutional Service Claim	XML	JSON
Simple Pharmacy Service Claim	XML	JSON
Simple Pharmacy Service Claim	XML	JSON