{

"resourceType": "Claim",
"id": "100151",
"identifier": [
  {
    "system": "http://happyvalley.com/claim",
    "value": "12346"
  }
],
"status": "active",
"type": {
  "coding": [
    {
      "system": "http://terminology.hl7.org/CodeSystem/claim-type",
      "code": "oral"
    }
  ]
},
"use": "claim",
"patient": {
  "reference": "Patient/1"
},
"created": "2014-08-16",
"insurer": {
  "reference": "Organization/2"
},
"provider": {
  "reference": "Organization/1"
},
"priority": {
  "coding": [
    {
      "code": "normal"
    }
  ]
},
"payee": {
  "type": {
    "coding": [
      {
        "code": "provider"
      }
    ]
  }
},
"careTeam": [
  {
    "sequence": 1,
    "provider": {
      "reference": "Practitioner/example"
    }
  }
],
"supportingInfo": [
  {
    "sequence": 1,
    "category": {
      "coding": [
        {
          "system": "http://terminology.hl7.org/CodeSystem/claiminformationcategory",
          "code": "missingtooth"
        }
      ]
    },
    "code": {
      "coding": [
        {
          "system": "http://terminology.hl7.org/CodeSystem/ex-tooth",
          "code": "15"
        }
      ]
    },
    "timingDate": "2012-04-07",
    "reason": {
      "coding": [
        {
          "system": "http://terminology.hl7.org/CodeSystem/missingtoothreason",
          "code": "e"
        }
      ]
    }
  },
  {
    "sequence": 2,
    "category": {
      "coding": [
        {
          "system": "http://terminology.hl7.org/CodeSystem/claiminformationcategory",
          "code": "exception"
        }
      ]
    },
    "code": {
      "coding": [
        {
          "system": "http://terminology.hl7.org/CodeSystem/claim-exception",
          "code": "student"
        }
      ]
    },
    "valueString": "Happy Valley Community College"
  }
],
"diagnosis": [
  {
    "sequence": 1,
    "diagnosisCodeableConcept": {
      "coding": [
        {
          "code": "123456"
        }
      ]
    }
  }
],
"insurance": [
  {
    "sequence": 1,
    "focal": true,
    "coverage": {
      "reference": "Coverage/9876B1"
    }
  }
],
"item": [
  {
    "sequence": 1,
    "careTeamSequence": [
      1
    ],
    "productOrService": {
      "coding": [
        {
          "system": "http://example.org/fhir/oralservicecodes",
          "code": "1200"
        }
      ]
    },
    "servicedDate": "2014-08-16",
    "unitPrice": {
      "value": 135.57,
      "currency": "USD"
    },
    "net": {
      "value": 135.57,
      "currency": "USD"
    }
  },
  {
    "sequence": 2,
    "careTeamSequence": [
      1
    ],
    "productOrService": {
      "coding": [
        {
          "system": "http://example.org/fhir/oralservicecodes",
          "code": "21211"
        }
      ]
    },
    "servicedDate": "2014-08-16",
    "unitPrice": {
      "value": 105.0,
      "currency": "USD"
    },
    "net": {
      "value": 105.0,
      "currency": "USD"
    },
    "bodySite": {
      "coding": [
        {
          "system": "http://fdi.org/fhir/oraltoothcodes",
          "code": "21"
        }
      ]
    },
    "subSite": [
      {
        "coding": [
          {
            "system": "http://fdi.org/fhir/oralsurfacecodes",
            "code": "L"
          }
        ]
      }
    ]
  },
  {
    "sequence": 3,
    "careTeamSequence": [
      1
    ],
    "productOrService": {
      "coding": [
        {
          "system": "http://example.org/fhir/oralservicecodes",
          "code": "27211"
        }
      ]
    },
    "servicedDate": "2014-08-16",
    "unitPrice": {
      "value": 1100.0,
      "currency": "USD"
    },
    "net": {
      "value": 1100.0,
      "currency": "USD"
    },
    "bodySite": {
      "coding": [
        {
          "system": "http://fdi.org/fhir/oraltoothcodes",
          "code": "36"
        }
      ]
    },
    "detail": [
      {
        "sequence": 1,
        "productOrService": {
          "coding": [
            {
              "system": "http://example.org/fhir/oralservicecodes",
              "code": "27211"
            }
          ]
        },
        "unitPrice": {
          "value": 1000.0,
          "currency": "USD"
        },
        "factor": 0.75,
        "net": {
          "value": 750.0,
          "currency": "USD"
        }
      },
      {
        "sequence": 2,
        "productOrService": {
          "coding": [
            {
              "system": "http://example.org/fhir/oralservicecodes",
              "code": "lab"
            }
          ]
        },
        "unitPrice": {
          "value": 350.0,
          "currency": "USD"
        },
        "net": {
          "value": 350.0,
          "currency": "USD"
        }
      }
    ]
  }
],
"meta": {
  "tag": [
    {
      "system": "http://terminology.hl7.org/CodeSystem/v3-ActReason",
      "code": "HTEST",
      "display": "test health data"
    }
  ]
}

}