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| Responsible Owner: Financial Management Work Group | Standards Status : Informative | Compartments : Device , Encounter , Group , Patient , Practitioner , RelatedPerson |
Raw JSON ( canonical form + also see JSON Format Specification )
Simple Pharmacy Compound Claim
Financial
{
"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>"
"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"
}
]
"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"
"use" : "claim",
"subject" : {
"reference" : "Patient/1"
},
"created": "2014-08-16",
"insurer": {
"reference": "Organization/2"
"created" : "2014-08-16",
"insurer" : {
"reference" : "Organization/2"
},
"provider": {
"reference": "Organization/1"
"provider" : {
"reference" : "Organization/1"
},
"priority": {
"coding": [
{
"code": "stat"
}
]
"priority" : {
"coding" : [{
"code" : "stat"
}]
},
"payee": {
"type": {
"coding": [
{
"code": "provider"
}
]
"payee" : {
"type" : {
"coding" : [{
"code" : "provider"
}]
}
},
"careTeam": [
{
"sequence": 1,
"provider": {
"reference": "Practitioner/example"
}
"careTeam" : [{
"sequence" : 1,
"provider" : {
"reference" : "Practitioner/example"
}
],
"supportingInfo": [
{
"sequence": 1,
"category": {
"coding": [
{
"code": "pharmacyrefill"
}
]
}],
"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://terminology.hl7.org/CodeSystem/v3-orderableDrugForm",
"code" : "TAB"
},
"net" : {
"value" : 155.00,
"currency" : "USD"
},
"detail" : [{
"sequence" : 1,
"productOrService" : {
"coding" : [{
"system" : "http://localdruglist.org",
"code" : "44001",
"display" : "Acetaminophen 250mg"
}]
},
"code": {
"coding": [
{
"system": "http://example.org/fhir/CodeSystem/pharmacy-refill",
"code": "new"
}
]
}
"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,
"category": {
"coding": [
{
"code": "pharmacyinformation"
}
]
"sequence" : 2,
"productOrService" : {
"coding" : [{
"system" : "http://localdruglist.org",
"code" : "44035",
"display" : "Phenacetin 50mg"
}]
},
"code": {
"coding": [
{
"system": "http://example.org/fhir/CodeSystem/pharmacy-information",
"code": "refillsremaining"
}
]
"quantity" : {
"value" : 50,
"unit" : "mg"
},
"valueQuantity": {
"value": 0
}
"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,
"category": {
"coding": [
{
"code": "pharmacyinformation"
}
]
"sequence" : 3,
"productOrService" : {
"coding" : [{
"system" : "http://localdruglist.org",
"code" : "44057",
"display" : "Codeine 25mg"
}]
},
"code": {
"coding": [
{
"system": "http://example.org/fhir/CodeSystem/pharmacy-information",
"code": "dayssupply"
}
]
"quantity" : {
"value" : 25,
"unit" : "mg"
},
"valueQuantity": {
"value": 10
}
"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": 4,
"category": {
"coding": [
{
"code": "pharmacy"
}
]
"sequence" : 2,
"productOrService" : {
"coding" : [{
"system" : "http://hl7.org/fhir/ex-pharmaservice",
"code" : "markup"
}]
},
"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"
"net" : {
"value" : 22.00,
"currency" : "USD"
}
}
],
"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"
"sequence" : 3,
"productOrService" : {
"coding" : [{
"system" : "http://hl7.org/fhir/ex-pharmaservice",
"code" : "compoundfee"
}]
},
"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"
"net" : {
"value" : 60.00,
"currency" : "USD"
}
}]
}],
"total" : {
"value" : 155.00,
"currency" : "USD"
}
}
Usage note: every effort has been made to ensure that the examples are correct and useful, but they are not a normative part of the specification.
FHIR
®©
HL7.org
2011+.
FHIR
Release
4
(Technical
Correction
#1)
(v4.0.1)
R6
hl7.fhir.core#6.0.0-ballot3
generated
on
Fri,
Mon,
Nov
1,
2019
09:34+1100.
QA
Page
10,
2025
15:21+0000.
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