FHIR IG analytics| Package | pharmacyeclaim.trial |
| Resource Type | Bundle |
| Id | ValidatedPharmacyDispenseRequest.json |
| FHIR Version | R4 |
No resources found
No resources found
No narrative content found in resource
FHIR
FHIRsmith{
"resourceType": "Bundle",
"id": "c149ce78-0983-4fc2-ba63-aeac253e933e",
"meta": {
"tag": [
{
"system": "http://pharmacyeclaims.ca/FHIR/CodeSystem/message-version",
"code": "1.0"
}
]
},
"type": "message",
"timestamp": "2025-01-06T22:03:23+00:00",
"entry": [
{
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},
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"value": "device-12345"
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"value": "IIN"
}
}
}
],
"sender": {
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"system": "urn:oid:setbyPOSvendor",
"value": "SoftwareVendorClientName"
}
},
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{
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"div": "<div xmlns=\"http://www.w3.org/1999/xhtml\">A human-readable rendering of the Pharmacy Claim</div>"
},
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{
"system": "urn:uri:happypharma123claim",
"value": "7612345"
},
{
"system": "http://pharmacyeclaims.ca/FHIR/CPHA-identifier/trace-number",
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}
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}
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],
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},
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"value": "123456"
}
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{
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{
"code": "dispense"
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}
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{
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"category": {
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{
"code": "SpecialAuth"
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]
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"valueString": "123"
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{
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"coding": [
{
"code": "RefillRemaining"
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]
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}
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"coding": [
{
"system": "http://hl7.org/fhir/sid/icd-10",
"code": "654456"
}
],
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{
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"coding": [
{
"system": "http://hl7.org/fhir/sid/icd-9",
"code": "16111"
}
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"text": "NameofDiagnosis2"
}
}
],
"insurance": [
{
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"focal": true,
"coverage": {
"reference": "urn:uuid:4e5af6dc-1f2a-4591-b09c-f4be8871431f"
}
},
{
"sequence": 2,
"focal": false,
"coverage": {
"reference": "urn:uuid:22222-1f2a-4591-b09c-22222"
},
"claimResponse": {
"reference": "urn:uuid:22222priorclaimresponse222"
}
}
],
"item": [
{
"sequence": 1,
"productOrService": {
"coding": [
{
"system": "http://localdruglist.org",
"code": "916111"
}
],
"text": "custom compound name"
},
"modifier": [
{
"coding": [
{
"system": "http://pharmacyeclaims.ca/FHIR/CodeSystem/intervention-codes",
"code": "MX"
}
]
},
{
"coding": [
{
"system": "http://pharmacyeclaims.ca/FHIR/CodeSystem/special-service-codes",
"code": "O"
}
]
}
],
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"quantity": {
"value": 30.5,
"unit": "mg",
"system": "http://terminology.hl7.org/CodeSystem/v3-orderableDrugForm",
"code": "TAB"
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"value": 155
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{
"system": "http://pharmacyeclaims.ca/FHIR/CodeSystem/adjudication-category-codes",
"code": "DrugCost"
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"productOrService": {
"coding": [
{
"system": "http://pharmacyeclaims.ca/FHIR/CodeSystem/adjudication-category-codes",
"code": "Upcharge"
}
]
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"value": 5
}
},
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"coding": [
{
"system": "http://pharmacyeclaims.ca/FHIR/CodeSystem/adjudication-category-codes",
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}
]
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}
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{
"system": "http://pharmacyeclaims.ca/FHIR/CodeSystem/adjudication-category-codes",
"code": "CompoundCharge"
}
]
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{
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"productOrService": {
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{
"system": "http://pharmacyeclaims.ca/FHIR/CodeSystem/adjudication-category-codes",
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"unit": "min"
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"system": "http://pharmacyeclaims.ca/FHIR/CodeSystem/adjudication-category-codes",
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}
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"productOrService": {
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{
"system": "http://pharmacyeclaims.ca/FHIR/CodeSystem/adjudication-category-codes",
"code": "QCProffFee"
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]
},
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}
},
{
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"productOrService": {
"coding": [
{
"system": "http://pharmacyeclaims.ca/FHIR/CodeSystem/adjudication-category-codes",
"code": "QCRefPrice"
}
]
},
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}
},
{
"sequence": 9,
"productOrService": {
"coding": [
{
"system": "http://pharmacyeclaims.ca/FHIR/CodeSystem/adjudication-category-codes",
"code": "QCRetailDispense"
}
]
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}
]
}
]
}
},
{
"fullUrl": "urn:uuid:b5c8a272-b078-4ac7-b53d-086968a8c716",
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"id": "b5c8a272-b078-4ac7-b53d-086968a8c716",
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{
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"value": "Identifier"
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"name": "BestPharmacyEver"
}
},
{
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"resource": {
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"id": "22222-1f2a-4591-b09c-22222",
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}
},
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]
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"identifier": {
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}
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"contract": [
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"value": "1234567891234"
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"identifier": {
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}
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}
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{
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"code": "JRX",
"display": "Jurisdictional Prescription Number"
}
]
},
"system": "http://example.org/prescriptions",
"value": "12345689"
},
{
"type": {
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"system": "http://terminology.hl7.org/CodeSystem/v2-0203",
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"value": "12345689"
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],
"status": "active",
"intent": "order",
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"system": "http://hl7.org/fhir/NamingSystem/ca-hc-din",
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}
],
"name": [
{
"family": "Tremblant",
"given": [
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]
}
],
"gender": "female",
"birthDate": "2018-06-23"
}
},
{
"fullUrl": "urn:uuid:db46f91d-f1a2-43ab-820a-03246da15555",
"resource": {
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"id": "db46f91d-f1a2-43ab-820a-03246da15555",
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{
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"id": "med0319",
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"system": "http://hl7.org/fhir/NamingSystem/ca-hc-din",
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"display": "PharmaSpecialOintment"
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"url": "http://pharmacyeclaims.ca/FHIR/v1.0/StructureDefinition/ext-ingredient-percentage-total-cost",
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{
"url": "http://pharmacyeclaims.ca/FHIR/v1.0/StructureDefinition/ext-IngredientQuantity",
"valueQuantity": {
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"unit": "mg",
"system": "http://unitsofmeasure.org",
"code": "mg"
}
}
],
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{
"system": "http://hl7.org/fhir/NamingSystem/ca-hc-din",
"code": "387253001",
"display": "Salicyclic Acid (substance)"
}
]
},
"isActive": true,
"strength": {
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"system": "http://unitsofmeasure.org",
"code": "g"
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"denominator": {
"value": 100,
"system": "http://unitsofmeasure.org",
"code": "g"
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}
},
{
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"url": "http://pharmacyeclaims.ca/FHIR/v1.0/StructureDefinition/ext-ingredient-percentage-total-cost",
"valueDecimal": 65
},
{
"url": "http://pharmacyeclaims.ca/FHIR/v1.0/StructureDefinition/ext-IngredientQuantity",
"valueQuantity": {
"value": 5,
"unit": "mg",
"system": "http://unitsofmeasure.org",
"code": "mg"
}
}
],
"itemCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/NamingSystem/OtherCompoundSubstance",
"code": "4545452",
"display": "White Petrolatum (substance)"
}
]
},
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"strength": {
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"value": 1,
"system": "http://unitsofmeasure.org",
"code": "g"
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"denominator": {
"value": 100,
"system": "http://unitsofmeasure.org",
"code": "g"
}
}
}
]
}
],
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{
"url": "http://pharmacyeclaims.ca/FHIR/v1.0/StructureDefinition/ext-RenderedDosageInstruction",
"valueString": "Take 1 tablet by mouth twice daily. Take with food. Take after meals."
}
],
"status": "completed",
"medicationReference": {
"reference": "#med0319"
},
"performer": [
{
"actor": {
"identifier": {
"system": "http://pharmacyeclaims.ca/FHIR/ValueSet/pharmacist-licence-identifier-system",
"value": "123456"
}
}
}
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]
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{
"system": "http://pharmacyeclaims.ca/FHIR/CodeSystem/claim-response-subType",
"code": "privateEHCPOL"
}
]
},
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"reference": "urn:uuid:db46f91d-f1a2-43ab-820a-03246da13580"
},
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"value": "11"
}
},
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"reference": "urn:uuid:primaryclaimrequstid"
},
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"disposition": "B",
"payeeType": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/payeetype",
"code": "provider"
}
]
},
"item": [
{
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"adjudication": [
{
"category": {
"coding": [
{
"code": "Co-pay"
}
]
},
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}
}
]
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{
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{
"category": {
"coding": [
{
"code": "Deductible"
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]
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"amount": {
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}
}
]
},
{
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"adjudication": [
{
"category": {
"coding": [
{
"code": "CoInsurance"
}
]
},
"amount": {
"value": 0
}
}
]
},
{
"itemSequence": 4,
"adjudication": [
{
"category": {
"coding": [
{
"code": "DrugCost"
}
]
},
"amount": {
"value": 40
}
}
]
},
{
"itemSequence": 5,
"adjudication": [
{
"category": {
"coding": [
{
"code": "Upcharge"
}
]
},
"amount": {
"value": 5
}
}
]
},
{
"itemSequence": 6,
"adjudication": [
{
"category": {
"coding": [
{
"code": "GenericIncentive"
}
]
},
"amount": {
"value": 5
}
}
]
},
{
"itemSequence": 8,
"adjudication": [
{
"category": {
"coding": [
{
"code": "ProfFee"
}
]
},
"amount": {
"value": 9
}
}
]
},
{
"itemSequence": 9,
"adjudication": [
{
"category": {
"coding": [
{
"code": "CompoundingCharge"
}
]
},
"amount": {
"value": 9
}
}
]
},
{
"itemSequence": 10,
"adjudication": [
{
"category": {
"coding": [
{
"code": "SSF"
}
]
},
"amount": {
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}
}
]
},
{
"itemSequence": 11,
"adjudication": [
{
"category": {
"coding": [
{
"code": "ResponseCode"
}
]
},
"reason": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication-reason",
"code": "ar002",
"display": "Optional display"
}
]
},
"amount": {
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}
}
]
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{
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"category": {
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"system": "http://terminology.hl7.org/CodeSystem/adjudication-reason",
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"display": "Optional display"
}
]
}
}
]
}
],
"payment": {
"type": {
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{
"system": "http://terminology.hl7.org/CodeSystem/ex-paymenttype",
"code": "complete"
}
]
},
"date": "2025-06-29",
"amount": {
"value": 100.47
}
},
"processNote": [
{
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"type": "display",
"text": "First adjudicator note",
"language": {
"coding": [
{
"system": "urn:ietf:bcp:47",
"code": "en-CA"
}
],
"text": "unknown"
}
},
{
"number": 2,
"type": "display",
"text": "Second adjudicator note",
"language": {
"coding": [
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"system": "urn:ietf:bcp:47",
"code": "en-CA"
}
]
}
}
]
}
}
]
}