R4 Ballot #1 (Mixed Normative/Trial use)

This page is part of the FHIR Specification (v3.3.0: R4 Ballot 2). The current version which supercedes this version is 5.0.0. For a full list of available versions, see the Directory of published versions . Page versions: R5 R4B R4 R3

Claim-example-pharmacy-medication.json

Financial Management Work GroupMaturity Level: N/ABallot Status: InformativeCompartments: Encounter, Patient, Practitioner, RelatedPerson

Raw JSON (canonical form)

Simple Pharmacy Medication Claim

{
  "resourceType": "Claim",
  "id": "760151",
  "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://hl7.org/fhir/claim-type",
        "code": "pharmacy"
      }
    ]
  },
  "use": "complete",
  "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"
      }
    }
  ],
  "information": [
    {
      "sequence": 1,
      "category": {
        "coding": [
          {
            "code": "pharmacyrefill"
          }
        ]
      },
      "code": {
        "coding": [
          {
            "system": "http://hl7.org/fhir/pharmacy-refill",
            "code": "new"
          }
        ]
      }
    },
    {
      "sequence": 2,
      "category": {
        "coding": [
          {
            "code": "pharmacyinformation"
          }
        ]
      },
      "code": {
        "coding": [
          {
            "system": "http://hl7.org/fhir/pharmacy-information",
            "code": "refillsremaining"
          }
        ]
      },
      "valueQuantity": {
        "value": 2
      }
    },
    {
      "sequence": 3,
      "category": {
        "coding": [
          {
            "code": "pharmacyinformation"
          }
        ]
      },
      "code": {
        "coding": [
          {
            "system": "http://hl7.org/fhir/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
      ],
      "service": {
        "coding": [
          {
            "system": "http://hl7.org/fhir/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,
        "system": "urn:iso:std:iso:4217",
        "code": "USD"
      },
      "detail": [
        {
          "sequence": 1,
          "service": {
            "coding": [
              {
                "system": "http://hl7.org/fhir/ex-pharmaservice",
                "code": "drugcost"
              }
            ]
          },
          "net": {
            "value": 45.00,
            "system": "urn:iso:std:iso:4217",
            "code": "USD"
          }
        },
        {
          "sequence": 2,
          "service": {
            "coding": [
              {
                "system": "http://hl7.org/fhir/ex-pharmaservice",
                "code": "markup"
              }
            ]
          },
          "net": {
            "value": 9.00,
            "system": "urn:iso:std:iso:4217",
            "code": "USD"
          }
        },
        {
          "sequence": 3,
          "service": {
            "coding": [
              {
                "system": "http://hl7.org/fhir/ex-pharmaservice",
                "code": "dispensefee"
              }
            ]
          },
          "net": {
            "value": 36.00,
            "system": "urn:iso:std:iso:4217",
            "code": "USD"
          }
        }
      ]
    }
  ],
  "total": {
    "value": 90.00,
    "system": "urn:iso:std:iso:4217",
    "code": "USD"
  }
}

Usage note: every effort has been made to ensure that the examples are correct and useful, but they are not a normative part of the specification.