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Resource "760151" Version "1" (Claim)

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XML or JSON representation . provenance for this resource

A human-readable rendering of the Pharmacy Claim

{
  "resourceType" : "Claim",
  "id" : "760151",
  "meta" : {
    "versionId" : "1",
    "lastUpdated" : "2018-12-14T02:01:33.942Z"
  },
  "text" : {
    "status" : "generated",
    "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\">A human-readable rendering of the Pharmacy Claim</div>"
  },
  "identifier" : [
    {
      "system" : "http://happypharma.com/claim",
      "value" : "7612345"
    }
  ],
  "status" : "active",
  "type" : {
    "coding" : [
      {
        "system" : "http://terminology.hl7.org/CodeSystem/claim-type",
        "code" : "pharmacy"
      }
    ]
  },
  "use" : "claim",
  "patient" : {
    "reference" : "Patient/1"
  },
  "created" : "2014-08-16",
  "insurer" : {
    "reference" : "Organization/2"
  },
  "provider" : {
    "reference" : "Organization/1"
  },
  "priority" : {
    "coding" : [
      {
        "code" : "stat"
      }
    ]
  },
  "prescription" : {
    "reference" : "http://pharmacy.org/MedicationRequest/AB1234G"
  },
  "originalPrescription" : {
    "reference" : "http://pharmacy.org/MedicationRequest/AB1202B"
  },
  "payee" : {
    "type" : {
      "coding" : [
        {
          "code" : "provider"
        }
      ]
    }
  },
  "careTeam" : [
    {
      "sequence" : 1,
      "provider" : {
        "reference" : "Practitioner/example"
      }
    }
  ],
  "supportingInfo" : [
    {
      "sequence" : 1,
      "category" : {
        "coding" : [
          {
            "code" : "pharmacyrefill"
          }
        ]
      },
      "code" : {
        "coding" : [
          {
            "system" : "http://example.org/fhir/CodeSystem/pharmacy-refill",
            "code" : "new"
          }
        ]
      }
    },
    {
      "sequence" : 2,
      "category" : {
        "coding" : [
          {
            "code" : "pharmacyinformation"
          }
        ]
      },
      "code" : {
        "coding" : [
          {
            "system" : "http://example.org/fhir/CodeSystem/pharmacy-information",
            "code" : "refillsremaining"
          }
        ]
      },
      "valueQuantity" : {
        "value" : 2
      }
    },
    {
      "sequence" : 3,
      "category" : {
        "coding" : [
          {
            "code" : "pharmacyinformation"
          }
        ]
      },
      "code" : {
        "coding" : [
          {
            "system" : "http://example.org/fhir/CodeSystem/pharmacy-information",
            "code" : "dayssupply"
          }
        ]
      },
      "valueQuantity" : {
        "value" : 90
      }
    }
  ],
  "diagnosis" : [
    {
      "sequence" : 1,
      "diagnosisCodeableConcept" : {
        "coding" : [
          {
            "code" : "654456"
          }
        ]
      }
    }
  ],
  "insurance" : [
    {
      "sequence" : 1,
      "focal" : true,
      "coverage" : {
        "reference" : "Coverage/9876B1"
      }
    }
  ],
  "item" : [
    {
      "sequence" : 1,
      "careTeamSequence" : [
        "1"
      ],
      "informationSequence" : [
        "1",
        "2",
        "3"
      ],
      "productOrService" : {
        "coding" : [
          {
            "system" : "http://www.nlm.nih.gov/research/umls/rxnorm",
            "code" : "562721",
            "display" : "Alprazolam 0.25mg (Xanax)"
          }
        ]
      },
      "servicedDate" : "2014-08-16",
      "quantity" : {
        "value" : 90,
        "unit" : "TAB",
        "system" : "http://unitsofmeasure.org",
        "code" : "TAB"
      },
      "net" : {
        "value" : 90.00,
        "currency" : "USD"
      },
      "detail" : [
        {
          "sequence" : 1,
          "productOrService" : {
            "coding" : [
              {
                "system" : "http://hl7.org/fhir/ex-pharmaservice",
                "code" : "drugcost"
              }
            ]
          },
          "net" : {
            "value" : 45.00,
            "currency" : "USD"
          }
        },
        {
          "sequence" : 2,
          "productOrService" : {
            "coding" : [
              {
                "system" : "http://hl7.org/fhir/ex-pharmaservice",
                "code" : "markup"
              }
            ]
          },
          "net" : {
            "value" : 9.00,
            "currency" : "USD"
          }
        },
        {
          "sequence" : 3,
          "productOrService" : {
            "coding" : [
              {
                "system" : "http://hl7.org/fhir/ex-pharmaservice",
                "code" : "dispensefee"
              }
            ]
          },
          "net" : {
            "value" : 36.00,
            "currency" : "USD"
          }
        }
      ]
    }
  ],
  "total" : {
    "value" : 90.00,
    "currency" : "USD"
  }
}