{
"resourceType": "Claim", "id": "100151", "text": { "status": "generated", "div": "<div>A human-readable rendering of the Oral Health Claim</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": "CSINV" }, "provider": { "reference": "Practitioner/example" }, "service": { "system": "http://hl7.org/fhir/oralservicecodes", "code": "1200" }, "serviceDate": "2014-08-16", "unitPrice": { "value": 135.57, "system": "urn:iso:std:iso:4217", "code": "USD" }, "net": { "value": 135.57, "system": "urn:iso:std:iso:4217", "code": "USD" } }, { "sequence": 2, "type": { "code": "CSINV" }, "provider": { "reference": "Practitioner/example" }, "service": { "system": "http://hl7.org/fhir/oralservicecodes", "code": "21211" }, "serviceDate": "2014-08-16", "unitPrice": { "value": 105.00, "system": "urn:iso:std:iso:4217", "code": "USD" }, "net": { "value": 105.00, "system": "urn:iso: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": "CPNDDRGING" }, "provider": { "reference": "Practitioner/example" }, "service": { "system": "http://hl7.org/fhir/oralservicecodes", "code": "27211" }, "serviceDate": "2014-08-16", "unitPrice": { "value": 1100.00, "system": "urn:iso:std:iso:4217", "code": "USD" }, "net": { "value": 1100.00, "system": "urn:iso:std:iso:4217", "code": "USD" }, "bodySite": { "system": "http://fdi.org/fhir/oraltoothcodes", "code": "36" }, "detail": [ { "sequence": 1, "type": { "code": "CSINV" }, "service": { "system": "http://hl7.org/fhir/oralservicecodes", "code": "27211" }, "unitPrice": { "value": 750.00, "system": "urn:iso:std:iso:4217", "code": "USD" }, "net": { "value": 750.00, "system": "urn:iso:std:iso:4217", "code": "USD" } }, { "sequence": 2, "type": { "code": "CSINV" }, "service": { "system": "http://hl7.org/fhir/oralservicecodes", "code": "lab" }, "unitPrice": { "value": 350.00, "system": "urn:iso:std:iso:4217", "code": "USD" }, "net": { "value": 350.00, "system": "urn:iso:std:iso:4217", "code": "USD" } } ] } ]
}