<?xml version=“1.0” encoding=“UTF-8”?> <Claim xmlns=“hl7.org/fhir”>
<id value="100151"/> <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://happyvalley.com/claim"/> <value value="12346"/> </identifier> <status value="active"/> <type> <coding> <system value="http://terminology.hl7.org/CodeSystem/claim-type"/> <code value="oral"/> </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> <payee> <type> <coding> <code value="provider"/> </coding> </type> </payee> <careTeam> <sequence value="1"/> <provider> <reference value="Practitioner/example"/> </provider> </careTeam> <supportingInfo> <sequence value="1"/> <category> <coding> <system value="http://terminology.hl7.org/CodeSystem/claiminformationcategory"/> <code value="missingtooth"/> </coding> </category> <code> <coding> <system value="http://terminology.hl7.org/CodeSystem/ex-tooth"/> <code value="15"/> </coding> </code> <timingDate value="2012-04-07"/> <reason> <coding> <system value="http://terminology.hl7.org/CodeSystem/missingtoothreason"/> <code value="e"/> <!-- Extraction --> </coding> </reason> </supportingInfo> <supportingInfo> <sequence value="2"/> <category> <coding> <system value="http://terminology.hl7.org/CodeSystem/claiminformationcategory"/> <code value="exception"/> </coding> </category> <code> <coding> <system value="http://terminology.hl7.org/CodeSystem/claim-exception"/> <code value="student"/> </coding> </code> <valueString value="Happy Valley Community College"/> </supportingInfo> <diagnosis> <sequence value="1"/> <diagnosisCodeableConcept> <coding> <code value="123456"/> </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/oralservicecodes"/> <code value="1200"/> </coding> </productOrService> <servicedDate value="2014-08-16"/> <unitPrice> <value value="135.57"/> <currency value="USD"/> </unitPrice> <net> <value value="135.57"/> <currency value="USD"/> </net> </item> <item> <sequence value="2"/> <careTeamSequence value="1"/> <productOrService> <coding> <system value="http://example.org/fhir/oralservicecodes"/> <code value="21211"/> </coding> </productOrService> <servicedDate value="2014-08-16"/> <unitPrice> <value value="105.00"/> <currency value="USD"/> </unitPrice> <net> <value value="105.00"/> <currency value="USD"/> </net> <bodySite> <coding> <system value="http://fdi.org/fhir/oraltoothcodes"/> <code value="21"/> </coding> </bodySite> <subSite> <coding> <system value="http://fdi.org/fhir/oralsurfacecodes"/> <code value="L"/> </coding> </subSite> </item> <item> <sequence value="3"/> <careTeamSequence value="1"/> <productOrService> <coding> <system value="http://example.org/fhir/oralservicecodes"/> <code value="27211"/> </coding> </productOrService> <servicedDate value="2014-08-16"/> <unitPrice> <value value="1100.00"/> <currency value="USD"/> </unitPrice> <net> <value value="1100.00"/> <currency value="USD"/> </net> <bodySite> <coding> <system value="http://fdi.org/fhir/oraltoothcodes"/> <code value="36"/> </coding> </bodySite> <detail> <sequence value="1"/> <productOrService> <coding> <system value="http://example.org/fhir/oralservicecodes"/> <code value="27211"/> </coding> </productOrService> <unitPrice> <value value="1000.00"/> <currency value="USD"/> </unitPrice> <factor value="0.75"/> <!-- Student discount --> <net> <value value="750.00"/> <currency value="USD"/> </net> </detail> <detail> <sequence value="2"/> <productOrService> <coding> <system value="http://example.org/fhir/oralservicecodes"/> <code value="lab"/> </coding> </productOrService> <unitPrice> <value value="350.00"/> <currency value="USD"/> </unitPrice> <net> <value value="350.00"/> <currency value="USD"/> </net> </detail> </item>
</Claim>