LinuxForHealth FHIR Implementation Guide
8.0.0 - draft
LinuxForHealth FHIR Implementation Guide - Local Development build (v8.0.0). See the Directory of published versions
<Claim xmlns="http://hl7.org/fhir">
<id value="CDMClaimDrugInstance"/>
<meta>
<extension
url="http://linuxforhealth.org/fhir/cdm/StructureDefinition/tenant-id">
<valueString value="tenant7209"/>
</extension>
<extension
url="http://linuxforhealth.org/fhir/cdm/StructureDefinition/ingestion-batch-id">
<valueString value="rgVCJnQBxvghkKTI8Hzz"/>
</extension>
<extension
url="http://linuxforhealth.org/fhir/cdm/StructureDefinition/process-name">
<valueString value="TREX"/>
</extension>
<extension
url="http://linuxforhealth.org/fhir/cdm/StructureDefinition/process-client-id">
<valueString value="7209"/>
</extension>
<extension
url="http://linuxforhealth.org/fhir/cdm/StructureDefinition/process-record-id">
<valueIdentifier>
<system value="http://acme-health.com/WellnessCenterPharmacy"/>
<value value="7209_07869_e00080779_3938586_2516181"/>
</valueIdentifier>
</extension>
<extension
url="http://linuxforhealth.org/fhir/cdm/StructureDefinition/source-file-id">
<valueString value="e00080779"/>
</extension>
<source value="http://acme-health.com/WellnessCenterPharmacy"/>
<profile
value="http://linuxforhealth.org/fhir/cdm/StructureDefinition/cdm-claim-drug"/>
</meta>
<text>
<status value="extensions"/>
<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>
</text>
<extension
url="http://linuxforhealth.org/fhir/cdm/StructureDefinition/snapshot-age-in-years">
<valueUnsignedInt value="20"/>
</extension>
<extension
url="http://linuxforhealth.org/fhir/cdm/StructureDefinition/aggregate-claim-indicator">
<valueString value="N"/>
</extension>
<extension
url="http://linuxforhealth.org/fhir/cdm/StructureDefinition/claim-snapshot-provider-name">
<valueString value="Dr Smith"/>
</extension>
<extension
url="http://linuxforhealth.org/fhir/cdm/StructureDefinition/claim-snapshot-provider-zip-code">
<valueString value="79912"/>
</extension>
<extension
url="http://linuxforhealth.org/fhir/cdm/StructureDefinition/company-code">
<valueCodeableConcept>
<coding>
<system value="http://acme-health.com/CodeSystem/local-company-code"/>
<code value="LocCompanyCd"/>
</coding>
</valueCodeableConcept>
</extension>
<extension
url="http://linuxforhealth.org/fhir/cdm/StructureDefinition/employee-business-unit">
<valueCodeableConcept>
<coding>
<system
value="http://acme-health.com/CodeSystem/local-employee-business-unit"/>
<code value="EmpBusUnit1"/>
</coding>
</valueCodeableConcept>
</extension>
<extension
url="http://linuxforhealth.org/fhir/cdm/StructureDefinition/employer">
<valueCodeableConcept>
<coding>
<system
value="http://acme-health.com/CodeSystem/local-employer-code"/>
<code value="EmployerCode1"/>
</coding>
</valueCodeableConcept>
</extension>
<extension
url="http://linuxforhealth.org/fhir/cdm/StructureDefinition/financial-system">
<valueCodeableConcept>
<coding>
<system
value="http://acme-health.com/CodeSystem/local-financial-system"/>
<code value="FinanceSys1"/>
</coding>
</valueCodeableConcept>
</extension>
<extension
url="http://linuxforhealth.org/fhir/cdm/StructureDefinition/claim-category">
<valueCodeableConcept>
<coding>
<system value="https://x12.org/codes/claim-status-category-codes"/>
<code value="F1"/>
</coding>
</valueCodeableConcept>
</extension>
<extension
url="http://linuxforhealth.org/fhir/cdm/StructureDefinition/claim-status">
<valueCodeableConcept>
<coding>
<system value="https://x12.org/codes/claim-status-codes"/>
<code value="F1"/>
</coding>
</valueCodeableConcept>
</extension>
<extension
url="http://linuxforhealth.org/fhir/cdm/StructureDefinition/last-claim-indicator">
<valueString value="Y"/>
</extension>
<extension
url="http://linuxforhealth.org/fhir/cdm/StructureDefinition/rx-count">
<valueUnsignedInt value="1"/>
</extension>
<extension
url="http://linuxforhealth.org/fhir/cdm/StructureDefinition/submission-type">
<valueCodeableConcept>
<coding>
<system
value="http://acme-health.com/CodeSystem/local-submission-type"/>
<code value="SubmitType1"/>
</coding>
</valueCodeableConcept>
</extension>
<extension
url="http://linuxforhealth.org/fhir/cdm/StructureDefinition/payer-pcp-responsibility-indicator">
<valueString value="N"/>
</extension>
<identifier>
<use value="official"/>
<type>
<coding>
<system
value="http://linuxforhealth.org/fhir/cdm/CodeSystem/identifier-type"/>
<code value="RXN"/>
</coding>
</type>
<system value="http://acme-health.com/CodeSystem/local-claim-identifier"/>
<value value="00000000000000000001921078"/>
<assigner>
<display value="Acme Health - Wellness Center Pharmacy"/>
</assigner>
</identifier>
<status value="active"/>
<type>
<coding>
<system
value="http://linuxforhealth.org/fhir/cdm/CodeSystem/payer-claim-type"/>
<code value="pharmacy"/>
</coding>
<coding>
<system value="http://acme-health.com/CodeSystem/local-claim-type"/>
<code value="Pharmacy"/>
</coding>
</type>
<use value="claim"/>
<patient>
<reference value="Patient/CDMPatientInstance"/>
</patient>
<created value="2017-07-25T17:31:00-05:00"/>
<provider>
<reference value="Organization/Provider1"/>
</provider>
<priority>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/processpriority"/>
<code value="normal"/>
</coding>
</priority>
<prescription>
<reference value="MedicationRequest/MedicationRequestDrugExample"/>
</prescription>
<careTeam>
<sequence value="1"/>
<provider>
<reference value="Practitioner/DrKelly"/>
</provider>
<role>
<coding>
<system
value="http://linuxforhealth.org/fhir/cdm/CodeSystem/claim-care-team-role"/>
<code value="ordering"/>
</coding>
</role>
</careTeam>
<careTeam>
<sequence value="2"/>
<provider>
<reference value="Organization/Payer1"/>
</provider>
<role>
<coding>
<system
value="http://linuxforhealth.org/fhir/cdm/CodeSystem/claim-care-team-role"/>
<code value="servicing"/>
</coding>
</role>
<qualification>
<coding>
<system value="http://acme-health.com/CodeSystem/local-specialty"/>
<code value="01"/>
</coding>
</qualification>
</careTeam>
<supportingInfo>
<sequence value="1"/>
<category>
<coding>
<system
value="http://linuxforhealth.org/fhir/cdm/CodeSystem/claim-supporting-info-category"/>
<code value="dayssupply"/>
</coding>
</category>
<valueQuantity>
<value value="30"/>
</valueQuantity>
</supportingInfo>
<supportingInfo>
<sequence value="2"/>
<category>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/claiminformationcategory"/>
<code value="info"/>
</coding>
</category>
<code>
<coding>
<system
value="http://linuxforhealth.org/fhir/cdm/CodeSystem/claim-supporting-info-type"/>
<code value="network-provider-indicator"/>
</coding>
</code>
<valueString value="Y"/>
</supportingInfo>
<supportingInfo>
<sequence value="3"/>
<category>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/claiminformationcategory"/>
<code value="info"/>
</coding>
</category>
<code>
<coding>
<system
value="http://linuxforhealth.org/fhir/cdm/CodeSystem/ncpdp-dispense-as-written"/>
<code value="8"/>
<display value="8"/>
</coding>
</code>
</supportingInfo>
<supportingInfo>
<sequence value="4"/>
<category>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/claiminformationcategory"/>
<code value="info"/>
</coding>
</category>
<code>
<coding>
<system
value="http://linuxforhealth.org/fhir/cdm/CodeSystem/claim-supporting-info-type"/>
<code value="refill-number"/>
</coding>
</code>
<valueQuantity>
<value value="4"/>
</valueQuantity>
</supportingInfo>
<supportingInfo>
<sequence value="5"/>
<category>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/claiminformationcategory"/>
<code value="info"/>
</coding>
</category>
<code>
<coding>
<system
value="http://linuxforhealth.org/fhir/cdm/CodeSystem/rx-mail-or-retail"/>
<code value="r"/>
</coding>
</code>
</supportingInfo>
<supportingInfo>
<sequence value="6"/>
<category>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/claiminformationcategory"/>
<code value="info"/>
</coding>
</category>
<code>
<coding>
<system
value="http://linuxforhealth.org/fhir/cdm/CodeSystem/claim-supporting-info-type"/>
<code value="compound-indicator"/>
</coding>
</code>
<valueString value="N"/>
</supportingInfo>
<supportingInfo>
<sequence value="7"/>
<category>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/claiminformationcategory"/>
<code value="info"/>
</coding>
</category>
<code>
<coding>
<system
value="http://acme-health.com/CodeSystem/local-dispensing-status"/>
<code value="LocalDispenseStatus"/>
<display value="Local dispensing status"/>
</coding>
</code>
<valueString value="N"/>
</supportingInfo>
<supportingInfo>
<sequence value="8"/>
<category>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/claiminformationcategory"/>
<code value="info"/>
</coding>
</category>
<code>
<coding>
<system value="http://acme-health.com/CodeSystem/local-rx-rebate"/>
<code value="LocalRxRebate"/>
<display value="Local RX rebate"/>
</coding>
</code>
<valueString value="Generic"/>
</supportingInfo>
<insurance>
<extension
url="http://linuxforhealth.org/fhir/cdm/StructureDefinition/crossover-indicator">
<valueString value="N"/>
</extension>
<extension
url="http://linuxforhealth.org/fhir/cdm/StructureDefinition/line-of-business">
<valueCodeableConcept>
<coding>
<system
value="http://acme-health.com/CodeSystem/local-line-of-business"/>
<code value="LocalLineOfBusiness"/>
</coding>
</valueCodeableConcept>
</extension>
<sequence value="1"/>
<focal value="true"/>
<identifier>
<system value="http://acme-health.com/insurer"/>
<value value="PPOB"/>
</identifier>
<coverage>
<reference value="Coverage/CoverageDrugExample"/>
</coverage>
</insurance>
<item>
<extension
url="http://linuxforhealth.org/fhir/cdm/StructureDefinition/compound-code">
<valueCodeableConcept>
<coding>
<system
value="http://acme-health.com/CodeSystem/local-compound-code"/>
<code value="CompoundCd1"/>
</coding>
</valueCodeableConcept>
</extension>
<extension
url="http://linuxforhealth.org/fhir/cdm/StructureDefinition/capitated-service-indicator">
<valueString value="N"/>
</extension>
<extension
url="http://linuxforhealth.org/fhir/cdm/StructureDefinition/fully-insured-indicator">
<valueString value="Y"/>
</extension>
<extension
url="http://linuxforhealth.org/fhir/cdm/StructureDefinition/nursing-home-indicator">
<valueString value="N"/>
</extension>
<sequence value="1"/>
<careTeamSequence value="1"/>
<productOrService>
<coding>
<system
value="http://linuxforhealth.org/fhir/cdm/CodeSystem/ndc-no-hyphens"/>
<code value="69452015120"/>
</coding>
<coding>
<system value="http://acme-health.com/CodeSystem/local-service-type"/>
<code value="LocServiceType"/>
</coding>
</productOrService>
<servicedDate value="2017-06-18"/>
<locationCodeableConcept>
<coding>
<system
value="https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set"/>
<code value="01"/>
<display value="Pharmacy"/>
</coding>
<coding>
<system
value="http://acme-health.com/CodeSystem/local-place-of-service"/>
<code value="LocalPlcOfService"/>
</coding>
</locationCodeableConcept>
<quantity>
<value value="30"/>
</quantity>
<net>
<value value="18.86"/>
</net>
<detail>
<extension
url="http://linuxforhealth.org/fhir/cdm/StructureDefinition/claim-item-detail-classification">
<valueCodeableConcept>
<coding>
<system
value="http://linuxforhealth.org/fhir/cdm/CodeSystem/claim-item-detail-classification"/>
<code value="dispensing-fee"/>
</coding>
</valueCodeableConcept>
</extension>
<sequence value="1"/>
<productOrService>
<coding>
<system
value="http://linuxforhealth.org/fhir/cdm/CodeSystem/ndc-no-hyphens"/>
<code value="69452015120"/>
</coding>
</productOrService>
<unitPrice>
<value value="2"/>
</unitPrice>
</detail>
<detail>
<extension
url="http://linuxforhealth.org/fhir/cdm/StructureDefinition/claim-item-detail-classification">
<valueCodeableConcept>
<coding>
<system
value="http://linuxforhealth.org/fhir/cdm/CodeSystem/claim-item-detail-classification"/>
<code value="ingredient-cost"/>
</coding>
</valueCodeableConcept>
</extension>
<sequence value="2"/>
<productOrService>
<coding>
<system
value="http://linuxforhealth.org/fhir/cdm/CodeSystem/ndc-no-hyphens"/>
<code value="69452015120"/>
</coding>
</productOrService>
<unitPrice>
<value value="3"/>
</unitPrice>
</detail>
<detail>
<extension
url="http://linuxforhealth.org/fhir/cdm/StructureDefinition/claim-item-detail-classification">
<valueCodeableConcept>
<coding>
<system
value="http://linuxforhealth.org/fhir/cdm/CodeSystem/claim-item-detail-classification"/>
<code value="sales-tax"/>
</coding>
</valueCodeableConcept>
</extension>
<sequence value="3"/>
<productOrService>
<coding>
<system
value="http://linuxforhealth.org/fhir/cdm/CodeSystem/ndc-no-hyphens"/>
<code value="69452015120"/>
</coding>
</productOrService>
<unitPrice>
<value value="1"/>
</unitPrice>
</detail>
</item>
</Claim>
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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