Claim Example: claim-example-pharmacy-compound

Narrative

A human-readable rendering of the Pharmacy Claim

Example XML

<?xml version="1.0" encoding="UTF-8"?>
<Claim xmlns="http://hl7.org/fhir" xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance" xsi:schemaLocation="http://hl7.org/fhir ../../schema/coverage.xsd">
    <id value="760152"/>

    <text>
        <status value="generated"/>
        <div xmlns="http://www.w3.org/1999/xhtml">A human-readable rendering of the Pharmacy Claim</div>
    </text>

    <identifier>
        <system value="http://happypharma.com/claim"/>
        <value value="7612345"/>
    </identifier>

    <status value = "active"/>

    <type>
        <coding>
            <system value="http://terminology.hl7.org/CodeSystem/claim-type"/>
            <code value="pharmacy"/>
        </coding>
    </type>

    <use value="claim"/>

    <subject>
        <reference value="Patient/1"/>
    </subject>

    <created value="2014-08-16"/>

    <insurer>
        <reference value="Organization/2"/>
    </insurer>

    <provider>
        <reference value="Organization/1"/>
    </provider>

    <priority>
        <coding>
            <code value="stat"/>
        </coding>
    </priority>

    <payee>
        <type>
            <coding>
                <code value="provider"/>
            </coding>
        </type>
    </payee>

    <careTeam>
        <sequence value="1"/>
        <provider>
            <reference value="Practitioner/example"/>
        </provider>
    </careTeam>

    <supportingInfo>
        <sequence value="1"/>
        <category>
            <coding>
                <code value="pharmacyrefill"/>
            </coding>
        </category>
        <code>
            <coding>
                <system value="http://example.org/fhir/CodeSystem/pharmacy-refill"/>
                <code value="new"/>
            </coding>
        </code>
    </supportingInfo>

    <supportingInfo>
        <sequence value="2"/>
        <category>
            <coding>
                <code value="pharmacyinformation"/>
            </coding>
        </category>
        <code>
            <coding>
                <system value="http://example.org/fhir/CodeSystem/pharmacy-information"/>
                <code value="refillsremaining"/>
            </coding>
        </code>
        <valueQuantity>
            <value value="0"/>
        </valueQuantity>
    </supportingInfo>

    <supportingInfo>
        <sequence value="3"/>
        <category>
            <coding>
                <code value="pharmacyinformation"/>
            </coding>
        </category>
        <code>
            <coding>
                <system value="http://example.org/fhir/CodeSystem/pharmacy-information"/>
                <code value="dayssupply"/>
            </coding>
        </code>
        <valueQuantity>
            <value value="10"/>
        </valueQuantity>
    </supportingInfo>

    <supportingInfo>
        <sequence value="4"/>
        <category>
            <coding>
                <code value="pharmacy"/>
            </coding>
        </category>
        <code>
            <coding>
                <system value="http://example.org/fhir/CodeSystem/pharmacy-form"/>
                <code value="capsule"/>
            </coding>
        </code>
    </supportingInfo>

    <diagnosis>
        <sequence value="1"/>
        <diagnosisCodeableConcept>
            <coding>
                <code value="654456"/>
            </coding>
        </diagnosisCodeableConcept>
    </diagnosis>

    <insurance>
        <sequence value="1"/>
        <focal value="true"/>
        <coverage>
            <reference value="Coverage/9876B1"/>
        </coverage>
    </insurance>

    <item>
        <sequence value="1"/>
        <careTeamSequence value="1"/>
        <informationSequence value="1"/>
        <informationSequence value="2"/>
        <informationSequence value="3"/>
        <informationSequence value="4"/>
        <!-- type=compoundmedication -->
        <productOrService>
            <coding>
                <system value="http://localdruglist.org"/>
                <code value="compound"/>
                <display value="Custom compound"/>
            </coding>
        </productOrService>
        <servicedDate value="2014-08-16"/>
        <quantity>
            <value value="30"/>
            <unit value="TAB"/>
            <system value="http://terminology.hl7.org/CodeSystem/v3-orderableDrugForm"/>
            <code value="TAB"/>
        </quantity>
        <net>
            <value value="155.00"/>
            <currency value="USD"/>
        </net>
        <detail>
            <sequence value="1"/>
            <!-- type=packagemedication -->
            <productOrService>
                <coding>
                    <system value="http://localdruglist.org"/>
                    <code value="44001"/>
                    <display value="Acetaminophen 250mg"/>
                </coding>
            </productOrService>
            <quantity>
                <value value="250"/>
                <unit value="mg"/>
            </quantity>
            <net>
                <value value="20.00"/>
                <currency value="USD"/>
            </net>
            <subDetail>
                <sequence value="1"/>
                <!-- type=costitem -->
                <productOrService>
                    <coding>
                        <system value="http://hl7.org/fhir/ex-pharmaservice"/>
                        <code value="drugcost"/>
                    </coding>
                </productOrService>
                <net>
                    <value value="20.00"/>
                    <currency value="USD"/>
                </net>
            </subDetail>
        </detail>
        <detail>
            <sequence value="2"/>
            <!-- type=packagemedication -->
            <productOrService>
                <coding>
                    <system value="http://localdruglist.org"/>
                    <code value="44035"/>
                    <display value="Phenacetin 50mg"/>
                </coding>
            </productOrService>
            <quantity>
                <value value="50"/>
                <unit value="mg"/>
            </quantity>
            <net>
                <value value="25.00"/>
                <currency value="USD"/>
            </net>
            <subDetail>
                <sequence value="1"/>
                <!-- type=costitem -->
                <productOrService>
                    <coding>
                        <system value="http://hl7.org/fhir/ex-pharmaservice"/>
                        <code value="drugcost"/>
                    </coding>
                </productOrService>
                <net>
                    <value value="25.00"/>
                    <currency value="USD"/>
                </net>
            </subDetail>
        </detail>
        <detail>
            <sequence value="3"/>
            <!-- type=packagemedication -->
            <productOrService>
                <coding>
                    <system value="http://localdruglist.org"/>
                    <code value="44057"/>
                    <display value="Codeine 25mg"/>
                </coding>
            </productOrService>
            <quantity>
                <value value="25"/>
                <unit value="mg"/>
            </quantity>
            <net>
                <value value="28.00"/>
                <currency value="USD"/>
            </net>
            <subDetail>
                <sequence value="1"/>
                <!-- type=costitem -->
                <productOrService>
                    <coding>
                        <system value="http://hl7.org/fhir/ex-pharmaservice"/>
                        <code value="drugcost"/>
                    </coding>
                </productOrService>
                <net>
                    <value value="28.00"/>
                    <currency value="USD"/>
                </net>
            </subDetail>
        </detail>
        <detail>
            <sequence value="2"/>
            <!-- type=costitem -->
            <productOrService>
                <coding>
                    <system value="http://hl7.org/fhir/ex-pharmaservice"/>
                    <code value="markup"/>
                </coding>
            </productOrService>
            <net>
                <value value="22.00"/>
                <currency value="USD"/>
            </net>
        </detail>
        <detail>
            <sequence value="3"/>
            <!-- type=costitem -->
            <productOrService>
                <coding>
                    <system value="http://hl7.org/fhir/ex-pharmaservice"/>
                    <code value="compoundfee"/>
                </coding>
            </productOrService>
            <net>
                <value value="60.00"/>
                <currency value="USD"/>
            </net>
        </detail>
    </item>
    <total>
        <value value="155.00"/>
        <currency value="USD"/>
    </total>
</Claim>