<?xml version=“1.0” encoding=“UTF-8”?> <Claim xmlns=“hl7.org/fhir”>
<id value="660151"/> <meta> <security> <system value="http://terminology.hl7.org/CodeSystem/v3-ActReason"/> <code value="HTEST"/> <display value="test health data"/> </security> </meta> <identifier> <system value="http://happysight.com/claim"/> <value value="6612346"/> </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/VisionPrescription/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> <sequence value="1"/> <focal value="true"/> <coverage> <reference value="Coverage/9876B1"/> </coverage> </insurance> <item> <sequence value="1"/> <careTeamSequence value="1"/> <productOrService> <coding> <system value="http://example.org/fhir/CodeSystem/ex-visionservice"/> <code value="glasses"/> </coding> </productOrService> <servicedDate value="2014-08-16"/> <unitPrice> <value value="214.00"/> <currency value="USD"/> </unitPrice> <net> <value value="214.00"/> <currency value="USD"/> </net> <detail> <sequence value="1"/> <productOrService> <coding> <system value="http://example.org/fhir/CodeSystem/ex-visionservice"/> <code value="frame"/> </coding> </productOrService> <unitPrice> <value value="100.00"/> <currency value="USD"/> </unitPrice> <net> <value value="100.00"/> <currency value="USD"/> </net> </detail> <detail> <sequence value="2"/> <productOrService> <coding> <system value="http://example.org/fhir/CodeSystem/ex-visionservice"/> <code value="lens"/> </coding> </productOrService> <quantity> <value value="2"/> </quantity> <unitPrice> <value value="50.00"/> <currency value="USD"/> </unitPrice> <net> <value value="100.00"/> <currency value="USD"/> </net> </detail> <detail> <sequence value="3"/> <productOrService> <coding> <system value="http://example.org/fhir/CodeSystem/ex-visionservice"/> <code value="fst"/> </coding> </productOrService> <unitPrice> <value value="200.00"/> <currency value="USD"/> </unitPrice> <factor value="0.07"/> <net> <value value="14.00"/> <currency value="USD"/> </net> </detail> </item>
</Claim>