Polaris FHIR Implementation Guide - Local Development build (v1.10.0) built by the FHIR (HL7® FHIR® Standard) Build Tools. See the Directory of published versions

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: Polaris Invoice Example - XML Representation

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<Invoice xmlns="http://hl7.org/fhir">
  <id value="polaris-invoice-example"/>
  <meta>
    <profile
             value="https://fhir.apps.health/StructureDefinition/polaris-core-invoice"/>
  </meta>
  <text>
    <status value="generated"/>
    <div xmlns="http://www.w3.org/1999/xhtml">OHIP bill for Avery Linwood, April 8, 2026 visit — general assessment A007 ($37.95) with chronic care premium K030. Total $61.45.</div>
  </text>
  <extension
             url="https://fhir.apps.health/StructureDefinition/oscar-billing-status-extension">
    <valueCode value="O"/>
  </extension>
  <extension
             url="https://fhir.apps.health/StructureDefinition/oscar-billing-shadow-bill-extension">
    <valueBoolean value="false"/>
  </extension>
  <extension
             url="https://fhir.apps.health/StructureDefinition/oscar-service-location-extension">
    <valueReference>🔗 
      <reference value="Location/cedarbrook-site-a"/>
    </valueReference>
  </extension>
  <identifier>
    <use value="official"/>
    <system
            value="https://fhir.apps.health/NamingSystem/cedarbrook-clinic-invoice-identifier"/>
    <value value="INV-avery-20250408-001"/>
  </identifier>
  <identifier>
    <use value="secondary"/>
    <system
            value="https://fhir.apps.health/NamingSystem/cedarbrook-clinic-invoice-header-id"/>
    <value value="78234"/>
  </identifier>
  <status value="issued"/>
  <type>
    <coding>
      <system
              value="https://fhir.apps.health/CodeSystem/oscar-pay-program-cs"/>
      <code value="HCP"/>
      <display value="OHIP HCP"/>
    </coding>
  </type>
  <subject>🔗 
    <reference value="Patient/avery-linwood"/>
  </subject>
  <date value="2026-04-08T10:15:00-04:00"/>
  <participant>
    <role>
      <text value="billing"/>
    </role>
    <actor>
      <reference value="Practitioner/dr-navarro"/>
    </actor>
  </participant>
  <issuer>🔗 
    <reference value="Organization/cedarbrook-clinic"/>
  </issuer>
  <lineItem>
    <extension url="https://apps.health/InvoiceLineItem/diagnostic1">
      <valueCodeableConcept>
        <coding>
          <system value="http://hl7.org/fhir/sid/icd-9-cm"/>
          <code value="250"/>
        </coding>
        <text value="Diabetes mellitus"/>
      </valueCodeableConcept>
    </extension>
    <sequence value="1"/>
    <chargeItemCodeableConcept>
      <coding>
        <system
                value="https://fhir.apps.health/CodeSystem/on-ohip-schedule-of-benefits"/>
        <code value="A007"/>
        <display value="General Assessment"/>
      </coding>
      <text value="General Assessment"/>
    </chargeItemCodeableConcept>
    <priceComponent>
      <type value="base"/>
      <factor value="1"/>
      <amount>
        <value value="37.95"/>
        <currency value="CAD"/>
      </amount>
    </priceComponent>
  </lineItem>
  <lineItem>
    <extension url="https://apps.health/InvoiceLineItem/diagnostic1">
      <valueCodeableConcept>
        <coding>
          <system value="http://hl7.org/fhir/sid/icd-9-cm"/>
          <code value="250"/>
        </coding>
        <text value="Diabetes mellitus"/>
      </valueCodeableConcept>
    </extension>
    <sequence value="2"/>
    <chargeItemCodeableConcept>
      <coding>
        <system
                value="https://fhir.apps.health/CodeSystem/on-ohip-schedule-of-benefits"/>
        <code value="K030"/>
        <display value="Chronic Disease Management Premium"/>
      </coding>
      <text value="Chronic Disease Management Premium"/>
    </chargeItemCodeableConcept>
    <priceComponent>
      <type value="base"/>
      <factor value="1"/>
      <amount>
        <value value="23.50"/>
        <currency value="CAD"/>
      </amount>
    </priceComponent>
  </lineItem>
  <totalGross>
    <value value="61.45"/>
    <currency value="CAD"/>
  </totalGross>
  <note>
    <text value="15-minute visit, diabetes management discussion"/>
  </note>
</Invoice>