FHIR IG analytics| Package | pharmacyeclaim.trial |
| Resource Type | Bundle |
| Id | ClaimResponseDispense3.json |
| FHIR Version | R4 |
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FHIR
FHIRsmith{
"resourceType": "Bundle",
"id": "c149ce78-0983-4fc2-ba63-aeac253e934e",
"meta": {
"tag": [
{
"system": "http://pharmacyeclaims.ca/FHIR/CodeSystem/message-version",
"code": "1.0"
}
]
},
"type": "message",
"timestamp": "2025-01-06T22:06:23+00:00",
"entry": [
{
"fullUrl": "urn:uuid:6d8041af-7963-4bff-baf4-968d600fbd1e",
"resource": {
"resourceType": "MessageHeader",
"id": "6d8041af-7963-4bff-baf4-968d600fbd1e",
"eventCoding": {
"system": "http://pharmacyeclaims.ca/fhir/CodeSystem/message-events",
"code": "51"
},
"destination": [
{
"name": "Name of Sending System",
"target": {
"reference": "Organization/b5c8a272-b078-4ac7-b53d-086968a8c716"
},
"endpoint": "urn:oid:2.16.840.1.113883.3.7066.2"
}
],
"source": {
"endpoint": "urn:uuid:2fcd0a14-4ad6-11e8-9c2d-fa7ae01bbebc"
},
"response": {
"identifier": "6d8041af-7963-4bff-baf4-968d600fbd1e",
"code": "ok"
},
"focus": [
{
"reference": "urn:uuid:6d8041af-7963-4bff-baf4-968d600fclrs"
}
]
}
},
{
"fullUrl": "urn:uuid:6d8041af-7963-4bff-baf4-968d600fclrs",
"resource": {
"resourceType": "ClaimResponse",
"id": "R3500",
"identifier": [
{
"system": "http://www.BenefitsInc.com/fhir/remittance",
"value": "R3500"
}
],
"status": "active",
"type": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/claim-type",
"code": "pharmacy"
}
]
},
"subType": {
"extension": [
{
"url": "http://pharmacyeclaims.ca/FHIR/v1.0/StructureDefinition/ext-Coverage-Program-Type",
"valueCode": "PlanType"
}
],
"coding": [
{
"system": "http://pharmacyeclaims.ca/FHIR/CodeSystem/claim-response-subType",
"code": "private"
}
]
},
"use": "claim",
"patient": {
"reference": "Patient/db46f91d-f1a2-43ab-820a-03246da13580",
"identifier": {
"system": "http://pharmacyeclaims.ca/FHIR/patient-identifier",
"value": "121"
}
},
"created": "2024-08-16",
"insurer": {
"reference": "Organization/b5c8a272-b078-4ac7-b53d-086968a8c716",
"identifier": {
"system": "http://pharmacyeclaims.ca/FHIR/CPHA-identifier/IIN",
"value": "11"
}
},
"request": {
"reference": "Claim/6d8041af-7963-4bff-baf4-968d600fbd1",
"identifier": {
"system": "http://pharmacyeclaims.ca/FHIR/CPHA-identifier/trace-number",
"value": "123456789"
},
"display": "TraceNumber B.23.03"
},
"outcome": "complete",
"disposition": "A",
"preAuthPeriod": {
"start": "2025-06-01",
"end": "2025-12-31"
},
"payeeType": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/payeetype",
"code": "provider"
}
]
},
"item": [
{
"itemSequence": 1,
"adjudication": [
{
"category": {
"coding": [
{
"code": "DrugCost"
}
]
},
"amount": {
"value": 300
}
},
{
"category": {
"coding": [
{
"code": "Upcharge"
}
]
},
"amount": {
"value": 10
}
},
{
"category": {
"coding": [
{
"code": "GenericIncentive"
}
]
},
"value": 80
},
{
"category": {
"coding": [
{
"code": "ProfFee"
}
]
},
"value": 90.47
},
{
"category": {
"coding": [
{
"code": "CompoundingCharge"
}
]
},
"value": 15
},
{
"category": {
"coding": [
{
"code": "SSF"
}
]
},
"value": 12
},
{
"category": {
"coding": [
{
"code": "Copay"
}
]
},
"value": 12
},
{
"category": {
"coding": [
{
"code": "Deductible"
}
]
},
"value": 12
},
{
"category": {
"coding": [
{
"code": "Co-Insurance"
}
]
},
"value": 5
},
{
"category": {
"coding": [
{
"code": "SATotalQuantityDispenseAccumulated"
}
]
},
"value": 87
},
{
"category": {
"coding": [
{
"code": "SARemainingQuantityAuth"
}
]
},
"value": 87
},
{
"category": {
"coding": [
{
"code": "SAApprovedDaysSupply"
}
]
},
"value": 87
},
{
"category": {
"coding": [
{
"code": "ResponseCode"
}
]
},
"reason": {
"coding": [
{
"system": "http://pharmacyeclaims.ca/FHIR/CodeSystem/FHIR-response-codes",
"code": "DJ"
}
]
}
},
{
"category": {
"coding": [
{
"code": "ResponseCode"
}
]
},
"reason": {
"coding": [
{
"system": "http://pharmacyeclaims.ca/FHIR/CodeSystem/FHIR-response-codes",
"code": "DH"
}
]
}
}
]
}
],
"payment": {
"type": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/ex-paymenttype",
"code": "complete"
}
]
},
"amount": {
"value": 100.47
}
},
"processNote": [
{
"extension": [
{
"url": "http://pharmacyeclaims.ca/FHIR/v1.0/StructureDefinition/ext-ProcessNoteDirectedTo",
"valueCode": "provider"
}
],
"number": 1,
"type": "display",
"text": "Please verify diagnosis coding for future claims.",
"language": {
"coding": [
{
"system": "urn:ietf:bcp:47",
"code": "en"
}
]
}
}
]
}
},
{
"fullUrl": "urn:uuid:db46f91d-f1a2-43ab-820a-03246da13580",
"resource": {
"resourceType": "Patient",
"id": "db46f91d-f1a2-43ab-820a-03246da13580",
"identifier": [
{
"type": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/v2-0203",
"code": "PLAC"
}
]
},
"system": "POSSystemIDTBD",
"value": "74359345"
},
{
"type": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/v2-0203",
"code": "JHN"
}
]
},
"system": "urn:oid:2.16.840.1.113883.4.20",
"value": "74359345"
}
],
"name": [
{
"family": "Tremblant",
"given": [
"Katia"
]
}
],
"gender": "female",
"birthDate": "2018-06-23"
}
},
{
"fullUrl": "urn:uuid:b5c8a272-b078-4ac7-b53d-086968a8c716",
"resource": {
"resourceType": "Organization",
"id": "b5c8a272-b078-4ac7-b53d-086968a8c716",
"identifier": [
{
"system": "urn:uuid:12345657575757",
"value": "InsurerID"
}
],
"name": "BestInsurerEver"
}
}
]
}