Claim-example-pharmacy-compound.json

Simple Pharmacy Compound Claim

{
  "resourceType": "Claim",
  "id": "760152",
  "text": {
    "status": "generated",
    "div": "<div xmlns=\"http://www.w3.org/1999/xhtml\">A human-readable rendering of the Pharmacy Claim</div>"
  },
  "identifier": [
    {
      "system": "http://happypharma.com/claim",
      "value": "7612345"
    }
  ],
  "status": "active",
  "type": {
    "coding": [
      {
        "system": "http://terminology.hl7.org/CodeSystem/claim-type",
        "code": "pharmacy"
      }
    ]
  },
  "use": "claim",
  "patient": {
    "reference": "Patient/1"
  },
  "created": "2014-08-16",
  "insurer": {
    "reference": "Organization/2"
  },
  "provider": {
    "reference": "Organization/1"
  },
  "priority": {
    "coding": [
      {
        "code": "stat"
      }
    ]
  },
  "payee": {
    "type": {
      "coding": [
        {
          "code": "provider"
        }
      ]
    }
  },
  "careTeam": [
    {
      "sequence": 1,
      "provider": {
        "reference": "Practitioner/example"
      }
    }
  ],
  "supportingInfo": [
    {
      "sequence": 1,
      "category": {
        "coding": [
          {
            "code": "pharmacyrefill"
          }
        ]
      },
      "code": {
        "coding": [
          {
            "system": "http://example.org/fhir/CodeSystem/pharmacy-refill",
            "code": "new"
          }
        ]
      }
    },
    {
      "sequence": 2,
      "category": {
        "coding": [
          {
            "code": "pharmacyinformation"
          }
        ]
      },
      "code": {
        "coding": [
          {
            "system": "http://example.org/fhir/CodeSystem/pharmacy-information",
            "code": "refillsremaining"
          }
        ]
      },
      "valueQuantity": {
        "value": 0
      }
    },
    {
      "sequence": 3,
      "category": {
        "coding": [
          {
            "code": "pharmacyinformation"
          }
        ]
      },
      "code": {
        "coding": [
          {
            "system": "http://example.org/fhir/CodeSystem/pharmacy-information",
            "code": "dayssupply"
          }
        ]
      },
      "valueQuantity": {
        "value": 10
      }
    },
    {
      "sequence": 4,
      "category": {
        "coding": [
          {
            "code": "pharmacy"
          }
        ]
      },
      "code": {
        "coding": [
          {
            "system": "http://example.org/fhir/CodeSystem/pharmacy-form",
            "code": "capsule"
          }
        ]
      }
    }
  ],
  "diagnosis": [
    {
      "sequence": 1,
      "diagnosisCodeableConcept": {
        "coding": [
          {
            "code": "654456"
          }
        ]
      }
    }
  ],
  "insurance": [
    {
      "sequence": 1,
      "focal": true,
      "coverage": {
        "reference": "Coverage/9876B1"
      }
    }
  ],
  "item": [
    {
      "sequence": 1,
      "careTeamSequence": [
        1
      ],
      "informationSequence": [
        1,
        2,
        3,
        4
      ],
      "productOrService": {
        "coding": [
          {
            "system": "http://localdruglist.org",
            "code": "compound",
            "display": "Custom compound"
          }
        ]
      },
      "servicedDate": "2014-08-16",
      "quantity": {
        "value": 30,
        "unit": "TAB",
        "system": "http://unitsofmeasure.org",
        "code": "TAB"
      },
      "net": {
        "value": 155.00,
        "currency": "USD"
      },
      "detail": [
        {
          "sequence": 1,
          "productOrService": {
            "coding": [
              {
                "system": "http://localdruglist.org",
                "code": "44001",
                "display": "Acetaminophen 250mg"
              }
            ]
          },
          "quantity": {
            "value": 250,
            "unit": "mg"
          },
          "net": {
            "value": 20.00,
            "currency": "USD"
          },
          "subDetail": [
            {
              "sequence": 1,
              "productOrService": {
                "coding": [
                  {
                    "system": "http://hl7.org/fhir/ex-pharmaservice",
                    "code": "drugcost"
                  }
                ]
              },
              "net": {
                "value": 20.00,
                "currency": "USD"
              }
            }
          ]
        },
        {
          "sequence": 2,
          "productOrService": {
            "coding": [
              {
                "system": "http://localdruglist.org",
                "code": "44035",
                "display": "Phenacetin 50mg"
              }
            ]
          },
          "quantity": {
            "value": 50,
            "unit": "mg"
          },
          "net": {
            "value": 25.00,
            "currency": "USD"
          },
          "subDetail": [
            {
              "sequence": 1,
              "productOrService": {
                "coding": [
                  {
                    "system": "http://hl7.org/fhir/ex-pharmaservice",
                    "code": "drugcost"
                  }
                ]
              },
              "net": {
                "value": 25.00,
                "currency": "USD"
              }
            }
          ]
        },
        {
          "sequence": 3,
          "productOrService": {
            "coding": [
              {
                "system": "http://localdruglist.org",
                "code": "44057",
                "display": "Codeine 25mg"
              }
            ]
          },
          "quantity": {
            "value": 25,
            "unit": "mg"
          },
          "net": {
            "value": 28.00,
            "currency": "USD"
          },
          "subDetail": [
            {
              "sequence": 1,
              "productOrService": {
                "coding": [
                  {
                    "system": "http://hl7.org/fhir/ex-pharmaservice",
                    "code": "drugcost"
                  }
                ]
              },
              "net": {
                "value": 28.00,
                "currency": "USD"
              }
            }
          ]
        },
        {
          "sequence": 2,
          "productOrService": {
            "coding": [
              {
                "system": "http://hl7.org/fhir/ex-pharmaservice",
                "code": "markup"
              }
            ]
          },
          "net": {
            "value": 22.00,
            "currency": "USD"
          }
        },
        {
          "sequence": 3,
          "productOrService": {
            "coding": [
              {
                "system": "http://hl7.org/fhir/ex-pharmaservice",
                "code": "compoundfee"
              }
            ]
          },
          "net": {
            "value": 60.00,
            "currency": "USD"
          }
        }
      ]
    }
  ],
  "total": {
    "value": 155.00,
    "currency": "USD"
  }
}