This page is part of the Consumer Real-time Pharmacy Benefit Check (v1.0.0: STU 1) based on FHIR R4. This is the current published version. For a full list of available versions, see the Directory of published versions

• Narrative Content
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• JSON
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: Example RTPBC Request (Claim) - JSON Representation

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{
  "resourceType" : "Claim",
  "id" : "rtpbc-claim-03",
  "meta" : {
    "versionId" : "4",
    "lastUpdated" : "2019-11-01T15:51:52.000-04:00",
    "profile" : [
      "http://hl7.org/fhir/us/carin-rtpbc/StructureDefinition/rtpbc-request-claim"
    ]
  },
  "text" : {
    "status" : "generated",
    "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p><b>Generated Narrative</b></p><p><b>id</b>: rtpbc-claim-03</p><p><b>meta</b>: </p><p><b>identifier</b>: id: rtpbc0001</p><p><b>status</b>: active</p><p><b>type</b>: <span title=\"Codes: {http://terminology.hl7.org/CodeSystem/claim-type pharmacy}\">Pharmacy</span></p><p><b>use</b>: predetermination</p><p><b>patient</b>: <a href=\"Patient-rtpbc-patient-03.html\">Generated Summary: id: rtpbc-patient-03; Patient internal identifier: 30455; Jane Doe ; gender: female; birthDate: 1975-12-05</a></p><p><b>created</b>: Nov 1, 2019 4:20:54 PM</p><p><b>provider</b>: <a href=\"Organization-rtpbc-organization-03.html\">Generated Summary: id: rtpbc-organization-03; id: 0999017; active; <span title=\"Codes: {http://ncpdp.org/pharmacy-type R}\">Retail</span>; name: Hometown Drug; ph: 6081234567</a></p><p><b>priority</b>: <span title=\"Codes: {http://terminology.hl7.org/CodeSystem/processpriority normal}\">Normal</span></p><p><b>prescription</b>: <a href=\"MedicationRequest-rtpbc-medicationrequest-03.html\">Generated Summary: id: rtpbc-medicationrequest-03; status: draft; intent: proposal; reported; <span title=\"Codes: {http://www.nlm.nih.gov/research/umls/rxnorm 205535}\">PROzac 10 MG Oral Capsule</span>; authoredOn: 2019-11-01</a></p><h3>CareTeams</h3><table class=\"grid\"><tr><td>-</td><td><b>Sequence</b></td><td><b>Provider</b></td></tr><tr><td>*</td><td>1</td><td><a href=\"Practitioner-rtpbc-practitioner-03.html\">Generated Summary: id: rtpbc-practitioner-03; id: 1234567890; Johnson </a></td></tr></table><h3>Insurances</h3><table class=\"grid\"><tr><td>-</td><td><b>Sequence</b></td><td><b>Focal</b></td><td><b>Coverage</b></td></tr><tr><td>*</td><td>1</td><td>true</td><td><a href=\"Coverage-rtpbc-coverage-03.html\">Generated Summary: id: rtpbc-coverage-03; status: active</a></td></tr></table><h3>Items</h3><table class=\"grid\"><tr><td>-</td><td><b>Sequence</b></td><td><b>CareTeamSequence</b></td><td><b>ProductOrService</b></td><td><b>Quantity</b></td></tr><tr><td>*</td><td>1</td><td>1</td><td><span title=\"Codes: {http://www.nlm.nih.gov/research/umls/rxnorm 205535}\">PROzac 10 MG Oral Capsule</span></td><td>60 {Each}</td></tr></table></div>"
  },
  "identifier" : [
    {
      "value" : "rtpbc0001"
    }
  ],
  "status" : "active",
  "type" : {
    "coding" : [
      {
        "system" : "http://terminology.hl7.org/CodeSystem/claim-type",
        "code" : "pharmacy",
        "display" : "Pharmacy"
      }
    ]
  },
  "use" : "predetermination",
  "patient" : {
    "reference" : "Patient/rtpbc-patient-03"
  },
  "created" : "2019-11-01T11:20:54-05:00",
  "provider" : {
    "reference" : "Organization/rtpbc-organization-03"
  },
  "priority" : {
    "coding" : [
      {
        "system" : "http://terminology.hl7.org/CodeSystem/processpriority",
        "code" : "normal",
        "display" : "Normal"
      }
    ]
  },
  "prescription" : {
    "reference" : "MedicationRequest/rtpbc-medicationrequest-03"
  },
  "careTeam" : [
    {
      "sequence" : 1,
      "provider" : {
        "reference" : "Practitioner/rtpbc-practitioner-03"
      }
    }
  ],
  "insurance" : [
    {
      "sequence" : 1,
      "focal" : true,
      "coverage" : {
        "reference" : "Coverage/rtpbc-coverage-03"
      }
    }
  ],
  "item" : [
    {
      "sequence" : 1,
      "careTeamSequence" : [
        1
      ],
      "productOrService" : {
        "coding" : [
          {
            "system" : "http://www.nlm.nih.gov/research/umls/rxnorm",
            "code" : "205535",
            "display" : "PROzac 10 MG Oral Capsule"
          }
        ]
      },
      "quantity" : {
        "value" : 60,
        "unit" : "{Each}"
      }
    }
  ]
}