Generated Narrative: Claim

Snapshot Age In Years: 20

Aggregate Claim Indicator: N

Claim Snapshot Provider Name: Dr Smith

Claim Snapshot Provider Zip Code: 79912

Company Code: LocCompanyCd (local-company-code#LocCompanyCd)

Employee Business Unit: EmpBusUnit1 (local-employee-business-unit#EmpBusUnit1)

Employer: EmployerCode1 (local-employer-code#EmployerCode1)

Financial System: FinanceSys1 (local-financial-system#FinanceSys1)

Claim Category: F1 (claim-status-category-codes#F1)

Claim Status: F1 (claim-status-codes#F1)

Last Claim Indicator: Y

RX Count: 1

Submission Type: SubmitType1 (local-submission-type#SubmitType1)

Payer PCP Responsibility Indicator: N

identifier: Prescription Number: 00000000000000000001921078(use: OFFICIAL)

status: active

type: Pharmacy; Pharmacy claims for goods and services (Payer Claim Type Codes#pharmacy; local-claim-type#Pharmacy)

use: claim

patient: Patient/CDMPatientInstance " MCLASTNAME"

created: 2017-07-25 05:31:00-0500

provider: Organization/Provider1 "Dr Smith"

priority: Normal (Process Priority Codes#normal)

prescription: MedicationRequest/MedicationRequestDrugExample

careTeam

sequence: 1

provider: Practitioner/DrKelly " KELLY"

role: Ordering provider (Claim Care Team Role Codes#ordering)

careTeam

sequence: 2

provider: Organization/Payer1 "Payer 1"

role: Servicing provider (Claim Care Team Role Codes#servicing)

qualification: 01 (local-specialty#01)

supportingInfo

sequence: 1

category: Day Supply (Claim Supporting Info Category Codes#dayssupply)

value: 30

supportingInfo

sequence: 2

category: Information (Claim Information Category Codes#info)

code: Network provider indicator (Claim Supporting Info Type Codes#network-provider-indicator)

value: Y

supportingInfo

sequence: 3

category: Information (Claim Information Category Codes#info)

code: 8 (NCPDP Dispense As Written Codes#8)

supportingInfo

sequence: 4

category: Information (Claim Information Category Codes#info)

code: Refill number (Claim Supporting Info Type Codes#refill-number)

value: 4

supportingInfo

sequence: 5

category: Information (Claim Information Category Codes#info)

code: Retail (Rx Mail Or Retail Codes#r)

supportingInfo

sequence: 6

category: Information (Claim Information Category Codes#info)

code: Drug compound indicator (Claim Supporting Info Type Codes#compound-indicator)

value: N

supportingInfo

sequence: 7

category: Information (Claim Information Category Codes#info)

code: Local dispensing status (local-dispensing-status#LocalDispenseStatus)

value: N

supportingInfo

sequence: 8

category: Information (Claim Information Category Codes#info)

code: Local RX rebate (local-rx-rebate#LocalRxRebate)

value: Generic

Insurances

item

Compound Code: CompoundCd1 (local-compound-code#CompoundCd1)

Capitated Service Indicator: N

Fully Insured Indicator: Y

Nursing Home Indicator: N

sequence: 1

careTeamSequence: 1

productOrService: 69452-0151-20 (NDC No Hyphens Codes#69452015120; local-service-type#LocServiceType)

serviced: 2017-06-18

location: Pharmacy (CMS Place of Service Codes (POS)#01; local-place-of-service#LocalPlcOfService)

quantity: 30

Nets

-	Value
*	18.86

detail

Claim Item Detail Classification: Dispensing Fee (Claim Item Detail Classification Codes#dispensing-fee)

sequence: 1

productOrService: 69452-0151-20 (NDC No Hyphens Codes#69452015120)

UnitPrices

-	Value
*	2

detail

Claim Item Detail Classification: Ingredient Cost (Claim Item Detail Classification Codes#ingredient-cost)

sequence: 2

productOrService: 69452-0151-20 (NDC No Hyphens Codes#69452015120)

UnitPrices

-	Value
*	3

detail

Claim Item Detail Classification: Sales Tax (Claim Item Detail Classification Codes#sales-tax)

sequence: 3

productOrService: 69452-0151-20 (NDC No Hyphens Codes#69452015120)

UnitPrices

-	Value
*	1