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Resource "760152" 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" : "760152",
  "meta" : {
    "versionId" : "1",
    "lastUpdated" : "2018-12-14T02:01:33.973Z"
  },
  "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"
      }
    ]
  },
  "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" : 0
      }
    },
    {
      "sequence" : 3,
      "category" : {
        "coding" : [
          {
            "code" : "pharmacyinformation"
          }
        ]
      },
      "code" : {
        "coding" : [
          {
            "system" : "http://example.org/fhir/CodeSystem/pharmacy-information",
            "code" : "dayssupply"
          }
        ]
      },
      "valueQuantity" : {
        "value" : 10
      }
    },
    {
      "sequence" : 4,
      "category" : {
        "coding" : [
          {
            "code" : "pharmacy"
          }
        ]
      },
      "code" : {
        "coding" : [
          {
            "system" : "http://example.org/fhir/CodeSystem/pharmacy-form",
            "code" : "capsule"
          }
        ]
      }
    }
  ],
  "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",
        "4"
      ],
      "productOrService" : {
        "coding" : [
          {
            "system" : "http://localdruglist.org",
            "code" : "compound",
            "display" : "Custom compound"
          }
        ]
      },
      "servicedDate" : "2014-08-16",
      "quantity" : {
        "value" : 30,
        "unit" : "TAB",
        "system" : "http://unitsofmeasure.org",
        "code" : "TAB"
      },
      "net" : {
        "value" : 155.00,
        "currency" : "USD"
      },
      "detail" : [
        {
          "sequence" : 1,
          "productOrService" : {
            "coding" : [
              {
                "system" : "http://localdruglist.org",
                "code" : "44001",
                "display" : "Acetaminophen 250mg"
              }
            ]
          },
          "quantity" : {
            "value" : 250,
            "unit" : "mg"
          },
          "net" : {
            "value" : 20.00,
            "currency" : "USD"
          },
          "subDetail" : [
            {
              "sequence" : 1,
              "productOrService" : {
                "coding" : [
                  {
                    "system" : "http://hl7.org/fhir/ex-pharmaservice",
                    "code" : "drugcost"
                  }
                ]
              },
              "net" : {
                "value" : 20.00,
                "currency" : "USD"
              }
            }
          ]
        },
        {
          "sequence" : 2,
          "productOrService" : {
            "coding" : [
              {
                "system" : "http://localdruglist.org",
                "code" : "44035",
                "display" : "Phenacetin 50mg"
              }
            ]
          },
          "quantity" : {
            "value" : 50,
            "unit" : "mg"
          },
          "net" : {
            "value" : 25.00,
            "currency" : "USD"
          },
          "subDetail" : [
            {
              "sequence" : 1,
              "productOrService" : {
                "coding" : [
                  {
                    "system" : "http://hl7.org/fhir/ex-pharmaservice",
                    "code" : "drugcost"
                  }
                ]
              },
              "net" : {
                "value" : 25.00,
                "currency" : "USD"
              }
            }
          ]
        },
        {
          "sequence" : 3,
          "productOrService" : {
            "coding" : [
              {
                "system" : "http://localdruglist.org",
                "code" : "44057",
                "display" : "Codeine 25mg"
              }
            ]
          },
          "quantity" : {
            "value" : 25,
            "unit" : "mg"
          },
          "net" : {
            "value" : 28.00,
            "currency" : "USD"
          },
          "subDetail" : [
            {
              "sequence" : 1,
              "productOrService" : {
                "coding" : [
                  {
                    "system" : "http://hl7.org/fhir/ex-pharmaservice",
                    "code" : "drugcost"
                  }
                ]
              },
              "net" : {
                "value" : 28.00,
                "currency" : "USD"
              }
            }
          ]
        },
        {
          "sequence" : 2,
          "productOrService" : {
            "coding" : [
              {
                "system" : "http://hl7.org/fhir/ex-pharmaservice",
                "code" : "markup"
              }
            ]
          },
          "net" : {
            "value" : 22.00,
            "currency" : "USD"
          }
        },
        {
          "sequence" : 3,
          "productOrService" : {
            "coding" : [
              {
                "system" : "http://hl7.org/fhir/ex-pharmaservice",
                "code" : "compoundfee"
              }
            ]
          },
          "net" : {
            "value" : 60.00,
            "currency" : "USD"
          }
        }
      ]
    }
  ],
  "total" : {
    "value" : 155.00,
    "currency" : "USD"
  }
}