{

"resourceType": "Claim",
"id": "660152",
"text": {
  "status": "generated",
  "div": "<div xmlns=\"http://www.w3.org/1999/xhtml\">A human-readable rendering of the Vision Claim for Glasses</div>"
},
"contained": [
  {
    "resourceType": "ClaimResponse",
    "id": "claimresponse-1",
    "identifier": [
      {
        "system": "http://thebenefircompany.com/claimresponse",
        "value": "CR6532875367"
      }
    ]
  },
  {
    "resourceType": "Device",
    "id": "device-frame"
  },
  {
    "resourceType": "Device",
    "id": "device-lens"
  }
],
"identifier": [
  {
    "system": "http://happysight.com/claim",
    "value": "6612347"
  }
],
"status": "active",
"type": {
  "coding": [
    {
      "system": "http://hl7.org/fhir/ex-claimtype",
      "code": "vision"
    }
  ]
},
"use": "complete",
"patient": {
  "reference": "Patient/1"
},
"created": "2014-08-16",
"insurer": {
  "reference": "Organization/2"
},
"organization": {
  "reference": "Organization/1"
},
"priority": {
  "coding": [
    {
      "code": "normal"
    }
  ]
},
"prescription": {
  "reference": "http://www.optdocs.com/VisionPrescription/12345"
},
"payee": {
  "type": {
    "coding": [
      {
        "code": "provider"
      }
    ]
  }
},
"careTeam": [
  {
    "sequence": 1,
    "provider": {
      "reference": "Practitioner/example"
    }
  }
],
"diagnosis": [
  {
    "sequence": 1,
    "diagnosisCodeableConcept": {
      "coding": [
        {
          "code": "654321"
        }
      ]
    }
  }
],
"insurance": [
  {
    "sequence": 1,
    "focal": false,
    "coverage": {
      "reference": "Coverage/9876B1"
    },
    "preAuthRef": [
      "PR7652387237"
    ],
    "claimResponse": {
      "reference": "#claimresponse-1"
    }
  },
  {
    "sequence": 2,
    "focal": true,
    "coverage": {
      "reference": "Coverage/9876B1"
    },
    "preAuthRef": [
      "AB543GTD7567"
    ]
  }
],
"item": [
  {
    "sequence": 1,
    "careTeamLinkId": [
      1
    ],
    "revenue": {
      "coding": [
        {
          "system": "http://hl7.org/fhir/ex-revenue-center",
          "code": "0010",
          "display": "Vision Clinic"
        }
      ]
    },
    "category": {
      "coding": [
        {
          "system": "http://hl7.org/fhir/benefit-subcategory",
          "code": "F6",
          "display": "Vision Coverage"
        }
      ]
    },
    "service": {
      "coding": [
        {
          "system": "http://hl7.org/fhir/ex-visionservice",
          "code": "glasses"
        }
      ]
    },
    "modifier": [
      {
        "coding": [
          {
            "system": "http://hl7.org/fhir/modifiers",
            "code": "rooh"
          }
        ]
      }
    ],
    "programCode": [
      {
        "coding": [
          {
            "system": "http://hl7.org/fhir/ex-programcode",
            "code": "none"
          }
        ]
      }
    ],
    "servicedDate": "2014-08-16",
    "unitPrice": {
      "value": 235.40,
      "system": "urn:iso:std:iso:4217",
      "code": "USD"
    },
    "net": {
      "value": 235.40,
      "system": "urn:iso:std:iso:4217",
      "code": "USD"
    },
    "detail": [
      {
        "sequence": 1,
        "revenue": {
          "coding": [
            {
              "system": "http://hl7.org/fhir/ex-revenue-center",
              "code": "0010",
              "display": "Vision Clinic"
            }
          ]
        },
        "category": {
          "coding": [
            {
              "system": "http://hl7.org/fhir/benefit-subcategory",
              "code": "F6",
              "display": "Vision Coverage"
            }
          ]
        },
        "service": {
          "coding": [
            {
              "system": "http://hl7.org/fhir/ex-visionservice",
              "code": "frame"
            }
          ]
        },
        "modifier": [
          {
            "coding": [
              {
                "system": "http://hl7.org/fhir/modifiers",
                "code": "rooh"
              }
            ]
          }
        ],
        "unitPrice": {
          "value": 100.00,
          "system": "urn:iso:std:iso:4217",
          "code": "USD"
        },
        "factor": 1.1,
        "net": {
          "value": 110.00,
          "system": "urn:iso:std:iso:4217",
          "code": "USD"
        },
        "udi": [
          {
            "reference": "#device-frame"
          }
        ]
      },
      {
        "sequence": 2,
        "revenue": {
          "coding": [
            {
              "system": "http://hl7.org/fhir/ex-revenue-center",
              "code": "0010",
              "display": "Vision Clinic"
            }
          ]
        },
        "category": {
          "coding": [
            {
              "system": "http://hl7.org/fhir/benefit-subcategory",
              "code": "F6",
              "display": "Vision Coverage"
            }
          ]
        },
        "service": {
          "coding": [
            {
              "system": "http://hl7.org/fhir/ex-visionservice",
              "code": "lens"
            }
          ]
        },
        "programCode": [
          {
            "coding": [
              {
                "system": "http://hl7.org/fhir/ex-programcode",
                "code": "none"
              }
            ]
          }
        ],
        "quantity": {
          "value": 2
        },
        "unitPrice": {
          "value": 55.00,
          "system": "urn:iso:std:iso:4217",
          "code": "USD"
        },
        "net": {
          "value": 110.00,
          "system": "urn:iso:std:iso:4217",
          "code": "USD"
        },
        "subDetail": [
          {
            "sequence": 1,
            "revenue": {
              "coding": [
                {
                  "system": "http://hl7.org/fhir/ex-revenue-center",
                  "code": "0010",
                  "display": "Vision Clinic"
                }
              ]
            },
            "category": {
              "coding": [
                {
                  "system": "http://hl7.org/fhir/benefit-subcategory",
                  "code": "F6",
                  "display": "Vision Coverage"
                }
              ]
            },
            "service": {
              "coding": [
                {
                  "system": "http://hl7.org/fhir/ex-visionservice",
                  "code": "lens"
                }
              ]
            },
            "modifier": [
              {
                "coding": [
                  {
                    "system": "http://hl7.org/fhir/modifiers",
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                ]
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            ],
            "programCode": [
              {
                "coding": [
                  {
                    "system": "http://hl7.org/fhir/ex-programcode",
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                  }
                ]
              }
            ],
            "quantity": {
              "value": 2
            },
            "unitPrice": {
              "value": 30.00,
              "system": "urn:iso:std:iso:4217",
              "code": "USD"
            },
            "factor": 1.1,
            "net": {
              "value": 66.00,
              "system": "urn:iso:std:iso:4217",
              "code": "USD"
            },
            "udi": [
              {
                "reference": "#device-lens"
              }
            ]
          },
          {
            "sequence": 2,
            "revenue": {
              "coding": [
                {
                  "system": "http://hl7.org/fhir/ex-revenue-center",
                  "code": "0010",
                  "display": "Vision Clinic"
                }
              ]
            },
            "category": {
              "coding": [
                {
                  "system": "http://hl7.org/fhir/benefit-subcategory",
                  "code": "F6",
                  "display": "Vision Coverage"
                }
              ]
            },
            "service": {
              "coding": [
                {
                  "system": "http://hl7.org/fhir/ex-visionservice",
                  "code": "hardening"
                }
              ]
            },
            "modifier": [
              {
                "coding": [
                  {
                    "system": "http://hl7.org/fhir/modifiers",
                    "code": "rooh"
                  }
                ]
              }
            ],
            "quantity": {
              "value": 2
            },
            "unitPrice": {
              "value": 15.00,
              "system": "urn:iso:std:iso:4217",
              "code": "USD"
            },
            "factor": 1.1,
            "net": {
              "value": 33.00,
              "system": "urn:iso:std:iso:4217",
              "code": "USD"
            }
          },
          {
            "sequence": 3,
            "revenue": {
              "coding": [
                {
                  "system": "http://hl7.org/fhir/ex-revenue-center",
                  "code": "0010",
                  "display": "Vision Clinic"
                }
              ]
            },
            "category": {
              "coding": [
                {
                  "system": "http://hl7.org/fhir/benefit-subcategory",
                  "code": "F6",
                  "display": "Vision Coverage"
                }
              ]
            },
            "service": {
              "coding": [
                {
                  "system": "http://hl7.org/fhir/ex-visionservice",
                  "code": "UV coating"
                }
              ]
            },
            "modifier": [
              {
                "coding": [
                  {
                    "system": "http://hl7.org/fhir/modifiers",
                    "code": "rooh"
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              "code": "USD"
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          }
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        "revenue": {
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              "system": "http://hl7.org/fhir/ex-revenue-center",
              "code": "0010",
              "display": "Vision Clinic"
            }
          ]
        },
        "category": {
          "coding": [
            {
              "system": "http://hl7.org/fhir/benefit-subcategory",
              "code": "F6",
              "display": "Vision Coverage"
            }
          ]
        },
        "service": {
          "coding": [
            {
              "system": "http://hl7.org/fhir/ex-visionservice",
              "code": "fst"
            }
          ]
        },
        "unitPrice": {
          "value": 220.00,
          "system": "urn:iso:std:iso:4217",
          "code": "USD"
        },
        "factor": 0.07,
        "net": {
          "value": 15.40,
          "system": "urn:iso:std:iso:4217",
          "code": "USD"
        }
      }
    ]
  }
]

}