CARIN Consumer Realtime Pharmacy Benefit Check
- CI Build

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

XML Format: Claim-rtpbc-claim-03

Raw xml 


<Claim xmlns="http://hl7.org/fhir">
  <id value="rtpbc-claim-03"/>
  <meta>
    <versionId value="4"/>
    <lastUpdated value="2019-11-01T15:51:52.000-04:00"/>
    <profile
             value="http://hl7.org/fhir/us/carin/StructureDefinition/rtpbc-request"/>
  </meta>
  <text>
    <status value="generated"/>
    <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>
  </text>
  <identifier>
    <value value="rtpbc0001"/>
  </identifier>
  <status value="active"/>
  <type>
    <coding>
      <system value="http://terminology.hl7.org/CodeSystem/claim-type"/>
      <code value="pharmacy"/>
      <display value="Pharmacy"/>
    </coding>
  </type>
  <use value="predetermination"/>
  <patient>
    <reference value="Patient/rtpbc-patient-03"/>
  </patient>
  <created value="2019-11-01T11:20:54-05:00"/>
  <provider>
    <reference value="Organization/rtpbc-organization-03"/>
  </provider>
  <priority>
    <coding>
      <system value="http://terminology.hl7.org/CodeSystem/processpriority"/>
      <code value="normal"/>
      <display value="Normal"/>
    </coding>
  </priority>
  <prescription>
    <reference value="MedicationRequest/rtpbc-medicationrequest-03"/>
  </prescription>
  <careTeam>
    <sequence value="1"/>
    <provider>
      <reference value="Practitioner/rtpbc-practitioner-03"/>
    </provider>
  </careTeam>
  <insurance>
    <sequence value="1"/>
    <focal value="true"/>
    <coverage>
      <reference value="Coverage/rtpbc-coverage-03"/>
    </coverage>
  </insurance>
  <item>
    <sequence value="1"/>
    <careTeamSequence value="1"/>
    <productOrService>
      <coding>
        <system value="http://terminology.hl7.org/CodeSystem/ndc-11"/>
        <code value="00777310402"/>
        <display value="Prozac 10mg capsule"/>
      </coding>
    </productOrService>
    <quantity>
      <value value="60"/>
      <unit value="EA"/>
    </quantity>
  </item>
</Claim>