Claim Example: claim-example-pharmacy-medication

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="760151"/>

    <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>

    <prescription>
        <reference value="http://pharmacy.org/MedicationRequest/AB1234G"/>
    </prescription>

    <originalPrescription>
        <reference value="http://pharmacy.org/MedicationRequest/AB1202B"/>
    </originalPrescription>

    <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="2"/>
        </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="90"/>
        </valueQuantity>
    </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"/>
        <!-- type=packagemedication -->
        <productOrService>
          <coding>
                <system value="http://www.nlm.nih.gov/research/umls/rxnorm"/>
                <code value="562721"/>
                <display value="amylase / cellulase / hyoscyamine / lipase / phenyltoloxamine / protease Oral Capsule"/>
                <!-- <display value="Alprazolam 0.25mg (Xanax)"/> -->
            </coding>
        </productOrService>
        <servicedDate value="2014-08-16"/>
        <quantity>
            <value value="90"/>
            <unit value="TAB"/>
            <system value="http://terminology.hl7.org/CodeSystem/v3-orderableDrugForm"/>
            <code value="TAB"/>
        </quantity>
        <net>
            <value value="90.00"/>
            <currency value="USD"/>
        </net>
        <detail>
            <sequence value="1"/>
            <!-- type=costitem -->
            <productOrService>
                <coding>
                    <system value="http://hl7.org/fhir/ex-pharmaservice"/>
                    <code value="drugcost"/>
                </coding>
            </productOrService>
            <net>
                <value value="45.00"/>
                <currency value="USD"/>
            </net>
        </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="9.00"/>
                <currency value="USD"/>
            </net>
        </detail>
        <detail>
            <sequence value="3"/>
            <!-- type=costitem -->
            <productOrService>
                <coding>
                    <system value="http://hl7.org/fhir/ex-pharmaservice"/>
                    <code value="dispensefee"/>
                </coding>
            </productOrService>
            <net>
                <value value="36.00"/>
                <currency value="USD"/>
            </net>
        </detail>
    </item>
    <total>
        <value value="90.00"/>
        <currency value="USD"/>
    </total>
</Claim>