Simple Pharmacy Medication Claim (id = "760151")

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

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

  <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> 

  <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>