This page is part of the Consumer Real-time Pharmacy Benefit Check (v0.1.0: STU 1 Ballot 1) based on FHIR R4. The current version which supercedes this version is 1.0.0. For a full list of available versions, see the Directory of published versions 
JSON Format: Claim-rtpbc-claim-03
Raw json
{
"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/StructureDefinition/rtpbc-request"
]
},
"text" : {
"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p><b>Generated Narrative with Details</b></p><p><b>id</b>: rtpbc-claim-03</p><p><b>meta</b>: </p><p><b>identifier</b>: rtpbc0001</p><p><b>status</b>: active</p><p><b>type</b>: Pharmacy <span style=\"background: LightGoldenRodYellow\">(Details : {http://terminology.hl7.org/CodeSystem/claim-type code 'pharmacy' = 'Pharmacy', given as '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; 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; 0999017; <span title=\"Codes: {http://ncpdp.org/pharmacy-type R}\">Retail</span>; name: Hometown Drug; ph: 6081234567</a></p><p><b>priority</b>: Normal <span style=\"background: LightGoldenRodYellow\">(Details : {http://terminology.hl7.org/CodeSystem/processpriority code 'normal' = 'Normal', given as '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://terminology.hl7.org/CodeSystem/ndc-11 00777310402}\">Prozac 10mg capsule</span></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; 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>Prozac 10mg capsule <span style=\"background: LightGoldenRodYellow\">(Details : {http://terminology.hl7.org/CodeSystem/ndc-11 code '00777310402' = 'Prozac 10mg capsule', given as 'Prozac 10mg capsule'})</span></td><td>60 EA</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://terminology.hl7.org/CodeSystem/ndc-11",
"code" : "00777310402",
"display" : "Prozac 10mg capsule"
}
]
},
"quantity" : {
"value" : 60,
"unit" : "EA"
}
}
]
}
