LinuxForHealth FHIR Implementation Guide
8.0.0 - draft
LinuxForHealth FHIR Implementation Guide - Local Development build (v8.0.0). See the Directory of published versions
{
"resourceType" : "Claim",
"id" : "CDMClaimDrugInstance",
"meta" : {
"extension" : [
{
"url" : "http://linuxforhealth.org/fhir/cdm/StructureDefinition/tenant-id",
"valueString" : "tenant7209"
},
{
"url" : "http://linuxforhealth.org/fhir/cdm/StructureDefinition/ingestion-batch-id",
"valueString" : "rgVCJnQBxvghkKTI8Hzz"
},
{
"url" : "http://linuxforhealth.org/fhir/cdm/StructureDefinition/process-name",
"valueString" : "TREX"
},
{
"url" : "http://linuxforhealth.org/fhir/cdm/StructureDefinition/process-client-id",
"valueString" : "7209"
},
{
"url" : "http://linuxforhealth.org/fhir/cdm/StructureDefinition/process-record-id",
"valueIdentifier" : {
"system" : "http://acme-health.com/WellnessCenterPharmacy",
"value" : "7209_07869_e00080779_3938586_2516181"
}
},
{
"url" : "http://linuxforhealth.org/fhir/cdm/StructureDefinition/source-file-id",
"valueString" : "e00080779"
}
],
"source" : "http://acme-health.com/WellnessCenterPharmacy",
"profile" : [
"http://linuxforhealth.org/fhir/cdm/StructureDefinition/cdm-claim-drug"
]
},
"text" : {
"status" : "extensions",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p><b>Generated Narrative: Claim</b><a name=\"CDMClaimDrugInstance\"> </a></p><div style=\"display: inline-block; background-color: #d9e0e7; padding: 6px; margin: 4px; border: 1px solid #8da1b4; border-radius: 5px; line-height: 60%\"><p style=\"margin-bottom: 0px\">Resource Claim \"CDMClaimDrugInstance\" </p><p style=\"margin-bottom: 0px\">Information Source: http://acme-health.com/WellnessCenterPharmacy!</p><p style=\"margin-bottom: 0px\">Profile: <a href=\"StructureDefinition-cdm-claim-drug.html\">CDM Claim Drug</a></p></div><p><b>Snapshot Age In Years</b>: 20</p><p><b>Aggregate Claim Indicator</b>: N</p><p><b>Claim Snapshot Provider Name</b>: Dr Smith</p><p><b>Claim Snapshot Provider Zip Code</b>: 79912</p><p><b>Company Code</b>: LocCompanyCd <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (local-company-code#LocCompanyCd)</span></p><p><b>Employee Business Unit</b>: EmpBusUnit1 <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (local-employee-business-unit#EmpBusUnit1)</span></p><p><b>Employer</b>: EmployerCode1 <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (local-employer-code#EmployerCode1)</span></p><p><b>Financial System</b>: FinanceSys1 <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (local-financial-system#FinanceSys1)</span></p><p><b>Claim Category</b>: F1 <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (claim-status-category-codes#F1)</span></p><p><b>Claim Status</b>: F1 <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (claim-status-codes#F1)</span></p><p><b>Last Claim Indicator</b>: Y</p><p><b>RX Count</b>: 1</p><p><b>Submission Type</b>: SubmitType1 <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (local-submission-type#SubmitType1)</span></p><p><b>Payer PCP Responsibility Indicator</b>: N</p><p><b>identifier</b>: Prescription Number: 00000000000000000001921078(use: OFFICIAL)</p><p><b>status</b>: active</p><p><b>type</b>: Pharmacy; Pharmacy claims for goods and services <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-payer-claim-type.html\">Payer Claim Type Codes</a>#pharmacy; local-claim-type#Pharmacy)</span></p><p><b>use</b>: claim</p><p><b>patient</b>: <a href=\"Patient-CDMPatientInstance.html\">Patient/CDMPatientInstance</a> \" MCLASTNAME\"</p><p><b>created</b>: 2017-07-25 05:31:00-0500</p><p><b>provider</b>: <a href=\"Organization-Provider1.html\">Organization/Provider1</a> \"Dr Smith\"</p><p><b>priority</b>: Normal <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"http://terminology.hl7.org/4.0.0/CodeSystem-processpriority.html\">Process Priority Codes</a>#normal)</span></p><p><b>prescription</b>: <a href=\"MedicationRequest-MedicationRequestDrugExample.html\">MedicationRequest/MedicationRequestDrugExample</a></p><blockquote><p><b>careTeam</b></p><p><b>sequence</b>: 1</p><p><b>provider</b>: <a href=\"Practitioner-DrKelly.html\">Practitioner/DrKelly</a> \" KELLY\"</p><p><b>role</b>: Ordering provider <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-claim-care-team-role.html\">Claim Care Team Role Codes</a>#ordering)</span></p></blockquote><blockquote><p><b>careTeam</b></p><p><b>sequence</b>: 2</p><p><b>provider</b>: <a href=\"Organization-Payer1.html\">Organization/Payer1</a> \"Payer 1\"</p><p><b>role</b>: Servicing provider <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-claim-care-team-role.html\">Claim Care Team Role Codes</a>#servicing)</span></p><p><b>qualification</b>: 01 <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (local-specialty#01)</span></p></blockquote><blockquote><p><b>supportingInfo</b></p><p><b>sequence</b>: 1</p><p><b>category</b>: Day Supply <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-claim-supporting-info-category.html\">Claim Supporting Info Category Codes</a>#dayssupply)</span></p><p><b>value</b>: 30</p></blockquote><blockquote><p><b>supportingInfo</b></p><p><b>sequence</b>: 2</p><p><b>category</b>: Information <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"http://terminology.hl7.org/4.0.0/CodeSystem-claiminformationcategory.html\">Claim Information Category Codes</a>#info)</span></p><p><b>code</b>: Network provider indicator <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-claim-supporting-info-type.html\">Claim Supporting Info Type Codes</a>#network-provider-indicator)</span></p><p><b>value</b>: Y</p></blockquote><blockquote><p><b>supportingInfo</b></p><p><b>sequence</b>: 3</p><p><b>category</b>: Information <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"http://terminology.hl7.org/4.0.0/CodeSystem-claiminformationcategory.html\">Claim Information Category Codes</a>#info)</span></p><p><b>code</b>: 8 <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-ncpdp-dispense-as-written.html\">NCPDP Dispense As Written Codes</a>#8)</span></p></blockquote><blockquote><p><b>supportingInfo</b></p><p><b>sequence</b>: 4</p><p><b>category</b>: Information <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"http://terminology.hl7.org/4.0.0/CodeSystem-claiminformationcategory.html\">Claim Information Category Codes</a>#info)</span></p><p><b>code</b>: Refill number <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-claim-supporting-info-type.html\">Claim Supporting Info Type Codes</a>#refill-number)</span></p><p><b>value</b>: 4</p></blockquote><blockquote><p><b>supportingInfo</b></p><p><b>sequence</b>: 5</p><p><b>category</b>: Information <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"http://terminology.hl7.org/4.0.0/CodeSystem-claiminformationcategory.html\">Claim Information Category Codes</a>#info)</span></p><p><b>code</b>: Retail <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-rx-mail-or-retail.html\">Rx Mail Or Retail Codes</a>#r)</span></p></blockquote><blockquote><p><b>supportingInfo</b></p><p><b>sequence</b>: 6</p><p><b>category</b>: Information <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"http://terminology.hl7.org/4.0.0/CodeSystem-claiminformationcategory.html\">Claim Information Category Codes</a>#info)</span></p><p><b>code</b>: Drug compound indicator <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-claim-supporting-info-type.html\">Claim Supporting Info Type Codes</a>#compound-indicator)</span></p><p><b>value</b>: N</p></blockquote><blockquote><p><b>supportingInfo</b></p><p><b>sequence</b>: 7</p><p><b>category</b>: Information <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"http://terminology.hl7.org/4.0.0/CodeSystem-claiminformationcategory.html\">Claim Information Category Codes</a>#info)</span></p><p><b>code</b>: Local dispensing status <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (local-dispensing-status#LocalDispenseStatus)</span></p><p><b>value</b>: N</p></blockquote><blockquote><p><b>supportingInfo</b></p><p><b>sequence</b>: 8</p><p><b>category</b>: Information <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"http://terminology.hl7.org/4.0.0/CodeSystem-claiminformationcategory.html\">Claim Information Category Codes</a>#info)</span></p><p><b>code</b>: Local RX rebate <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (local-rx-rebate#LocalRxRebate)</span></p><p><b>value</b>: Generic</p></blockquote><h3>Insurances</h3><table class=\"grid\"><tr><td>-</td><td><b>Extension</b></td><td><b>Sequence</b></td><td><b>Focal</b></td><td><b>Identifier</b></td><td><b>Coverage</b></td></tr><tr><td>*</td><td>, </td><td>1</td><td>true</td><td>id: PPOB</td><td><a href=\"Coverage-CoverageDrugExample.html\">Coverage/CoverageDrugExample</a></td></tr></table><blockquote><p><b>item</b></p><p><b>Compound Code</b>: CompoundCd1 <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (local-compound-code#CompoundCd1)</span></p><p><b>Capitated Service Indicator</b>: N</p><p><b>Fully Insured Indicator</b>: Y</p><p><b>Nursing Home Indicator</b>: N</p><p><b>sequence</b>: 1</p><p><b>careTeamSequence</b>: 1</p><p><b>productOrService</b>: 69452-0151-20 <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-ndc-no-hyphens.html\">NDC No Hyphens Codes</a>#69452015120; local-service-type#LocServiceType)</span></p><p><b>serviced</b>: 2017-06-18</p><p><b>location</b>: Pharmacy <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"http://terminology.hl7.org/4.0.0/CodeSystem-CMSPlaceofServiceCodes.html\">CMS Place of Service Codes (POS)</a>#01; local-place-of-service#LocalPlcOfService)</span></p><p><b>quantity</b>: 30</p><h3>Nets</h3><table class=\"grid\"><tr><td>-</td><td><b>Value</b></td></tr><tr><td>*</td><td>18.86</td></tr></table><blockquote><p><b>detail</b></p><p><b>Claim Item Detail Classification</b>: Dispensing Fee <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-claim-item-detail-classification.html\">Claim Item Detail Classification Codes</a>#dispensing-fee)</span></p><p><b>sequence</b>: 1</p><p><b>productOrService</b>: 69452-0151-20 <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-ndc-no-hyphens.html\">NDC No Hyphens Codes</a>#69452015120)</span></p><h3>UnitPrices</h3><table class=\"grid\"><tr><td>-</td><td><b>Value</b></td></tr><tr><td>*</td><td>2</td></tr></table></blockquote><blockquote><p><b>detail</b></p><p><b>Claim Item Detail Classification</b>: Ingredient Cost <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-claim-item-detail-classification.html\">Claim Item Detail Classification Codes</a>#ingredient-cost)</span></p><p><b>sequence</b>: 2</p><p><b>productOrService</b>: 69452-0151-20 <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-ndc-no-hyphens.html\">NDC No Hyphens Codes</a>#69452015120)</span></p><h3>UnitPrices</h3><table class=\"grid\"><tr><td>-</td><td><b>Value</b></td></tr><tr><td>*</td><td>3</td></tr></table></blockquote><blockquote><p><b>detail</b></p><p><b>Claim Item Detail Classification</b>: Sales Tax <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-claim-item-detail-classification.html\">Claim Item Detail Classification Codes</a>#sales-tax)</span></p><p><b>sequence</b>: 3</p><p><b>productOrService</b>: 69452-0151-20 <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-ndc-no-hyphens.html\">NDC No Hyphens Codes</a>#69452015120)</span></p><h3>UnitPrices</h3><table class=\"grid\"><tr><td>-</td><td><b>Value</b></td></tr><tr><td>*</td><td>1</td></tr></table></blockquote></blockquote></div>"
},
"extension" : [
{
"url" : "http://linuxforhealth.org/fhir/cdm/StructureDefinition/snapshot-age-in-years",
"valueUnsignedInt" : 20
},
{
"url" : "http://linuxforhealth.org/fhir/cdm/StructureDefinition/aggregate-claim-indicator",
"valueString" : "N"
},
{
"url" : "http://linuxforhealth.org/fhir/cdm/StructureDefinition/claim-snapshot-provider-name",
"valueString" : "Dr Smith"
},
{
"url" : "http://linuxforhealth.org/fhir/cdm/StructureDefinition/claim-snapshot-provider-zip-code",
"valueString" : "79912"
},
{
"url" : "http://linuxforhealth.org/fhir/cdm/StructureDefinition/company-code",
"valueCodeableConcept" : {
"coding" : [
{
"system" : "http://acme-health.com/CodeSystem/local-company-code",
"code" : "LocCompanyCd"
}
]
}
},
{
"url" : "http://linuxforhealth.org/fhir/cdm/StructureDefinition/employee-business-unit",
"valueCodeableConcept" : {
"coding" : [
{
"system" : "http://acme-health.com/CodeSystem/local-employee-business-unit",
"code" : "EmpBusUnit1"
}
]
}
},
{
"url" : "http://linuxforhealth.org/fhir/cdm/StructureDefinition/employer",
"valueCodeableConcept" : {
"coding" : [
{
"system" : "http://acme-health.com/CodeSystem/local-employer-code",
"code" : "EmployerCode1"
}
]
}
},
{
"url" : "http://linuxforhealth.org/fhir/cdm/StructureDefinition/financial-system",
"valueCodeableConcept" : {
"coding" : [
{
"system" : "http://acme-health.com/CodeSystem/local-financial-system",
"code" : "FinanceSys1"
}
]
}
},
{
"url" : "http://linuxforhealth.org/fhir/cdm/StructureDefinition/claim-category",
"valueCodeableConcept" : {
"coding" : [
{
"system" : "https://x12.org/codes/claim-status-category-codes",
"code" : "F1"
}
]
}
},
{
"url" : "http://linuxforhealth.org/fhir/cdm/StructureDefinition/claim-status",
"valueCodeableConcept" : {
"coding" : [
{
"system" : "https://x12.org/codes/claim-status-codes",
"code" : "F1"
}
]
}
},
{
"url" : "http://linuxforhealth.org/fhir/cdm/StructureDefinition/last-claim-indicator",
"valueString" : "Y"
},
{
"url" : "http://linuxforhealth.org/fhir/cdm/StructureDefinition/rx-count",
"valueUnsignedInt" : 1
},
{
"url" : "http://linuxforhealth.org/fhir/cdm/StructureDefinition/submission-type",
"valueCodeableConcept" : {
"coding" : [
{
"system" : "http://acme-health.com/CodeSystem/local-submission-type",
"code" : "SubmitType1"
}
]
}
},
{
"url" : "http://linuxforhealth.org/fhir/cdm/StructureDefinition/payer-pcp-responsibility-indicator",
"valueString" : "N"
}
],
"identifier" : [
{
"use" : "official",
"type" : {
"coding" : [
{
"system" : "http://linuxforhealth.org/fhir/cdm/CodeSystem/identifier-type",
"code" : "RXN"
}
]
},
"system" : "http://acme-health.com/CodeSystem/local-claim-identifier",
"value" : "00000000000000000001921078",
"assigner" : {
"display" : "Acme Health - Wellness Center Pharmacy"
}
}
],
"status" : "active",
"type" : {
"coding" : [
{
"system" : "http://linuxforhealth.org/fhir/cdm/CodeSystem/payer-claim-type",
"code" : "pharmacy"
},
{
"system" : "http://acme-health.com/CodeSystem/local-claim-type",
"code" : "Pharmacy"
}
]
},
"use" : "claim",
"patient" : {
"reference" : "Patient/CDMPatientInstance"
},
"created" : "2017-07-25T17:31:00-05:00",
"provider" : {
"reference" : "Organization/Provider1"
},
"priority" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/processpriority",
"code" : "normal"
}
]
},
"prescription" : {
"reference" : "MedicationRequest/MedicationRequestDrugExample"
},
"careTeam" : [
{
"sequence" : 1,
"provider" : {
"reference" : "Practitioner/DrKelly"
},
"role" : {
"coding" : [
{
"system" : "http://linuxforhealth.org/fhir/cdm/CodeSystem/claim-care-team-role",
"code" : "ordering"
}
]
}
},
{
"sequence" : 2,
"provider" : {
"reference" : "Organization/Payer1"
},
"role" : {
"coding" : [
{
"system" : "http://linuxforhealth.org/fhir/cdm/CodeSystem/claim-care-team-role",
"code" : "servicing"
}
]
},
"qualification" : {
"coding" : [
{
"system" : "http://acme-health.com/CodeSystem/local-specialty",
"code" : "01"
}
]
}
}
],
"supportingInfo" : [
{
"sequence" : 1,
"category" : {
"coding" : [
{
"system" : "http://linuxforhealth.org/fhir/cdm/CodeSystem/claim-supporting-info-category",
"code" : "dayssupply"
}
]
},
"valueQuantity" : {
"value" : 30
}
},
{
"sequence" : 2,
"category" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/claiminformationcategory",
"code" : "info"
}
]
},
"code" : {
"coding" : [
{
"system" : "http://linuxforhealth.org/fhir/cdm/CodeSystem/claim-supporting-info-type",
"code" : "network-provider-indicator"
}
]
},
"valueString" : "Y"
},
{
"sequence" : 3,
"category" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/claiminformationcategory",
"code" : "info"
}
]
},
"code" : {
"coding" : [
{
"system" : "http://linuxforhealth.org/fhir/cdm/CodeSystem/ncpdp-dispense-as-written",
"code" : "8",
"display" : "8"
}
]
}
},
{
"sequence" : 4,
"category" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/claiminformationcategory",
"code" : "info"
}
]
},
"code" : {
"coding" : [
{
"system" : "http://linuxforhealth.org/fhir/cdm/CodeSystem/claim-supporting-info-type",
"code" : "refill-number"
}
]
},
"valueQuantity" : {
"value" : 4
}
},
{
"sequence" : 5,
"category" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/claiminformationcategory",
"code" : "info"
}
]
},
"code" : {
"coding" : [
{
"system" : "http://linuxforhealth.org/fhir/cdm/CodeSystem/rx-mail-or-retail",
"code" : "r"
}
]
}
},
{
"sequence" : 6,
"category" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/claiminformationcategory",
"code" : "info"
}
]
},
"code" : {
"coding" : [
{
"system" : "http://linuxforhealth.org/fhir/cdm/CodeSystem/claim-supporting-info-type",
"code" : "compound-indicator"
}
]
},
"valueString" : "N"
},
{
"sequence" : 7,
"category" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/claiminformationcategory",
"code" : "info"
}
]
},
"code" : {
"coding" : [
{
"system" : "http://acme-health.com/CodeSystem/local-dispensing-status",
"code" : "LocalDispenseStatus",
"display" : "Local dispensing status"
}
]
},
"valueString" : "N"
},
{
"sequence" : 8,
"category" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/claiminformationcategory",
"code" : "info"
}
]
},
"code" : {
"coding" : [
{
"system" : "http://acme-health.com/CodeSystem/local-rx-rebate",
"code" : "LocalRxRebate",
"display" : "Local RX rebate"
}
]
},
"valueString" : "Generic"
}
],
"insurance" : [
{
"extension" : [
{
"url" : "http://linuxforhealth.org/fhir/cdm/StructureDefinition/crossover-indicator",
"valueString" : "N"
},
{
"url" : "http://linuxforhealth.org/fhir/cdm/StructureDefinition/line-of-business",
"valueCodeableConcept" : {
"coding" : [
{
"system" : "http://acme-health.com/CodeSystem/local-line-of-business",
"code" : "LocalLineOfBusiness"
}
]
}
}
],
"sequence" : 1,
"focal" : true,
"identifier" : {
"system" : "http://acme-health.com/insurer",
"value" : "PPOB"
},
"coverage" : {
"reference" : "Coverage/CoverageDrugExample"
}
}
],
"item" : [
{
"extension" : [
{
"url" : "http://linuxforhealth.org/fhir/cdm/StructureDefinition/compound-code",
"valueCodeableConcept" : {
"coding" : [
{
"system" : "http://acme-health.com/CodeSystem/local-compound-code",
"code" : "CompoundCd1"
}
]
}
},
{
"url" : "http://linuxforhealth.org/fhir/cdm/StructureDefinition/capitated-service-indicator",
"valueString" : "N"
},
{
"url" : "http://linuxforhealth.org/fhir/cdm/StructureDefinition/fully-insured-indicator",
"valueString" : "Y"
},
{
"url" : "http://linuxforhealth.org/fhir/cdm/StructureDefinition/nursing-home-indicator",
"valueString" : "N"
}
],
"sequence" : 1,
"careTeamSequence" : [
1
],
"productOrService" : {
"coding" : [
{
"system" : "http://linuxforhealth.org/fhir/cdm/CodeSystem/ndc-no-hyphens",
"code" : "69452015120"
},
{
"system" : "http://acme-health.com/CodeSystem/local-service-type",
"code" : "LocServiceType"
}
]
},
"servicedDate" : "2017-06-18",
"locationCodeableConcept" : {
"coding" : [
{
"system" : "https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set",
"code" : "01",
"display" : "Pharmacy"
},
{
"system" : "http://acme-health.com/CodeSystem/local-place-of-service",
"code" : "LocalPlcOfService"
}
]
},
"quantity" : {
"value" : 30
},
"net" : {
"value" : 18.86
},
"detail" : [
{
"extension" : [
{
"url" : "http://linuxforhealth.org/fhir/cdm/StructureDefinition/claim-item-detail-classification",
"valueCodeableConcept" : {
"coding" : [
{
"system" : "http://linuxforhealth.org/fhir/cdm/CodeSystem/claim-item-detail-classification",
"code" : "dispensing-fee"
}
]
}
}
],
"sequence" : 1,
"productOrService" : {
"coding" : [
{
"system" : "http://linuxforhealth.org/fhir/cdm/CodeSystem/ndc-no-hyphens",
"code" : "69452015120"
}
]
},
"unitPrice" : {
"value" : 2
}
},
{
"extension" : [
{
"url" : "http://linuxforhealth.org/fhir/cdm/StructureDefinition/claim-item-detail-classification",
"valueCodeableConcept" : {
"coding" : [
{
"system" : "http://linuxforhealth.org/fhir/cdm/CodeSystem/claim-item-detail-classification",
"code" : "ingredient-cost"
}
]
}
}
],
"sequence" : 2,
"productOrService" : {
"coding" : [
{
"system" : "http://linuxforhealth.org/fhir/cdm/CodeSystem/ndc-no-hyphens",
"code" : "69452015120"
}
]
},
"unitPrice" : {
"value" : 3
}
},
{
"extension" : [
{
"url" : "http://linuxforhealth.org/fhir/cdm/StructureDefinition/claim-item-detail-classification",
"valueCodeableConcept" : {
"coding" : [
{
"system" : "http://linuxforhealth.org/fhir/cdm/CodeSystem/claim-item-detail-classification",
"code" : "sales-tax"
}
]
}
}
],
"sequence" : 3,
"productOrService" : {
"coding" : [
{
"system" : "http://linuxforhealth.org/fhir/cdm/CodeSystem/ndc-no-hyphens",
"code" : "69452015120"
}
]
},
"unitPrice" : {
"value" : 1
}
}
]
}
]
}
IG © 2021+ LinuxForHealth Team. Package linuxforhealth.fhir.ig#8.0.0 based on FHIR 4.0.1. Generated 2022-11-10
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