Release 5 Ballot

This page is part of the FHIR Specification (v5.0.0-ballot: FHIR R5 Ballot Preview). 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

Example Claim/760152 (XML)

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

Raw XML (canonical form + also see XML Format Specification)

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Simple Pharmacy Compound Claim (id = "760152")

<?xml version="1.0" encoding="UTF-8"?>

<Claim xmlns="http://hl7.org/fhir">
  <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"/> 

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

  <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>

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.