fhir-react
Version:
React component library for displaying FHIR Resources
419 lines • 11.8 kB
JSON
{
"information": [
{
"category": {
"coding": [
{
"system": "https://bluebutton.cms.gov/resources/codesystem/information",
"code": "https://bluebutton.cms.gov/resources/variables/daw_prod_slctn_cd",
"display": "Dispense as Written (DAW) Product Selection Code"
}
]
},
"sequence": 1,
"code": {
"coding": [
{
"system": "https://bluebutton.cms.gov/resources/variables/daw_prod_slctn_cd",
"code": "0",
"display": "No Product Selection Indicated (may also have missing values)"
}
]
}
},
{
"category": {
"coding": [
{
"system": "https://bluebutton.cms.gov/resources/codesystem/information",
"code": "https://bluebutton.cms.gov/resources/variables/dspnsng_stus_cd",
"display": "Dispensing Status Code"
}
]
},
"sequence": 2,
"code": {
"coding": [
{
"system": "https://bluebutton.cms.gov/resources/variables/dspnsng_stus_cd",
"code": "C",
"display": "Completion of partial fill"
}
]
}
},
{
"category": {
"coding": [
{
"system": "https://bluebutton.cms.gov/resources/codesystem/information",
"code": "https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd",
"display": "Drug Coverage Status Code"
}
]
},
"sequence": 3,
"code": {
"coding": [
{
"system": "https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd",
"code": "C",
"display": "Covered"
}
]
}
},
{
"category": {
"coding": [
{
"system": "https://bluebutton.cms.gov/resources/codesystem/information",
"code": "https://bluebutton.cms.gov/resources/variables/rx_orgn_cd",
"display": "Prescription Origination Code"
}
]
},
"sequence": 4,
"code": {
"coding": [
{
"system": "https://bluebutton.cms.gov/resources/variables/rx_orgn_cd",
"code": "3",
"display": "Electronic"
}
]
}
},
{
"category": {
"coding": [
{
"system": "https://bluebutton.cms.gov/resources/codesystem/information",
"code": "https://bluebutton.cms.gov/resources/variables/brnd_gnrc_cd",
"display": "Brand-Generic Code Reported by Submitting Plan"
}
]
},
"sequence": 5,
"code": {
"coding": [
{
"system": "https://bluebutton.cms.gov/resources/variables/brnd_gnrc_cd",
"code": "G",
"display": "Generic Null/missing"
}
]
}
},
{
"category": {
"coding": [
{
"system": "https://bluebutton.cms.gov/resources/codesystem/information",
"code": "https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd",
"display": "Pharmacy service type code"
}
]
},
"sequence": 6,
"code": {
"coding": [
{
"system": "https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd"
}
]
}
},
{
"category": {
"coding": [
{
"system": "https://bluebutton.cms.gov/resources/codesystem/information",
"code": "https://bluebutton.cms.gov/resources/variables/ptnt_rsdnc_cd",
"display": "Patient Residence Code"
}
]
},
"sequence": 7,
"code": {
"coding": [
{
"system": "https://bluebutton.cms.gov/resources/variables/ptnt_rsdnc_cd",
"code": "90"
}
]
}
},
{
"category": {
"coding": [
{
"system": "https://bluebutton.cms.gov/resources/codesystem/information",
"code": "https://bluebutton.cms.gov/resources/variables/submsn_clr_cd",
"display": "Submission clarification code"
}
]
},
"sequence": 8,
"code": {
"coding": [
{
"system": "https://bluebutton.cms.gov/resources/variables/submsn_clr_cd",
"code": "21",
"display": "LTC dispensing rule for <=14 day supply is not applicable due to CMS exclusion or the fact that the manufacturer’s packaging does not allow for special dispensing"
}
]
}
}
],
"facility": {
"identifier": {
"value": "999999999999999",
"system": "http://hl7.org/fhir/sid/us-npi"
}
},
"identifier": [
{
"value": "-3410339348",
"system": "https://bluebutton.cms.gov/resources/variables/pde_id"
},
{
"value": "4669765623",
"system": "https://bluebutton.cms.gov/resources/identifier/claim-group"
},
{
"value": "33437629246",
"system": "https://bluebutton.cms.gov/resources/variables/rx_srvc_rfrnc_num"
}
],
"meta": {
"lastUpdated": "2020-01-10T08:42:58.808Z",
"versionId": "9000000000000"
},
"status": "active",
"item": [
{
"adjudication": [
{
"category": {
"coding": [
{
"system": "https://bluebutton.cms.gov/resources/codesystem/adjudication",
"code": "https://bluebutton.cms.gov/resources/variables/cvrd_d_plan_pd_amt",
"display": "Amount paid by Part D plan for the PDE (drug is covered by Part D)"
}
]
},
"reason": {
"coding": [
{
"system": "https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd",
"code": "C",
"display": "Covered"
}
]
},
"amount": {
"value": 0,
"system": "urn:iso:std:iso:4217",
"code": "USD"
}
},
{
"category": {
"coding": [
{
"system": "https://bluebutton.cms.gov/resources/codesystem/adjudication",
"code": "https://bluebutton.cms.gov/resources/variables/gdc_blw_oopt_amt",
"display": "Gross Drug Cost Below Part D Out-of-Pocket Threshold (GDCB)"
}
]
},
"amount": {
"value": 0,
"system": "urn:iso:std:iso:4217",
"code": "USD"
}
},
{
"category": {
"coding": [
{
"system": "https://bluebutton.cms.gov/resources/codesystem/adjudication",
"code": "https://bluebutton.cms.gov/resources/variables/gdc_abv_oopt_amt",
"display": "Gross Drug Cost Above Part D Out-of-Pocket Threshold (GDCA)"
}
]
},
"amount": {
"value": 0,
"system": "urn:iso:std:iso:4217",
"code": "USD"
}
},
{
"category": {
"coding": [
{
"system": "https://bluebutton.cms.gov/resources/codesystem/adjudication",
"code": "https://bluebutton.cms.gov/resources/variables/ptnt_pay_amt",
"display": "Amount Paid by Patient"
}
]
},
"amount": {
"value": 0,
"system": "urn:iso:std:iso:4217",
"code": "USD"
}
},
{
"category": {
"coding": [
{
"system": "https://bluebutton.cms.gov/resources/codesystem/adjudication",
"code": "https://bluebutton.cms.gov/resources/variables/othr_troop_amt",
"display": "Other True Out-of-Pocket (TrOOP) Amount"
}
]
},
"amount": {
"value": 0,
"system": "urn:iso:std:iso:4217",
"code": "USD"
}
},
{
"category": {
"coding": [
{
"system": "https://bluebutton.cms.gov/resources/codesystem/adjudication",
"code": "https://bluebutton.cms.gov/resources/variables/lics_amt",
"display": "Amount paid for the PDE by Part D low income subsidy"
}
]
},
"amount": {
"value": 0,
"system": "urn:iso:std:iso:4217",
"code": "USD"
}
},
{
"category": {
"coding": [
{
"system": "https://bluebutton.cms.gov/resources/codesystem/adjudication",
"code": "https://bluebutton.cms.gov/resources/variables/plro_amt",
"display": "Reduction in patient liability due to payments by other payers (PLRO)"
}
]
},
"amount": {
"value": 0,
"system": "urn:iso:std:iso:4217",
"code": "USD"
}
},
{
"category": {
"coding": [
{
"system": "https://bluebutton.cms.gov/resources/codesystem/adjudication",
"code": "https://bluebutton.cms.gov/resources/variables/tot_rx_cst_amt",
"display": "Total drug cost (Part D)"
}
]
},
"amount": {
"value": 0,
"system": "urn:iso:std:iso:4217",
"code": "USD"
}
},
{
"category": {
"coding": [
{
"system": "https://bluebutton.cms.gov/resources/codesystem/adjudication",
"code": "https://bluebutton.cms.gov/resources/variables/rptd_gap_dscnt_num",
"display": "Gap Discount Amount"
}
]
},
"amount": {
"value": 0,
"system": "urn:iso:std:iso:4217",
"code": "USD"
}
}
],
"sequence": 1,
"servicedDate": "2016-06-01",
"quantity": {
"value": 30
},
"careTeamLinkId": [
2
],
"service": {
"coding": [
{
"system": "http://hl7.org/fhir/sid/ndc",
"code": "60505257908",
"display": "ATORVASTATIN CALCIUM - ATORVASTATIN CALCIUM TRIHYDRATE"
}
]
}
}
],
"patient": {
"reference": "Patient/dc793caf0d58"
},
"organization": {
"identifier": {
"value": "999999999999999",
"system": "http://hl7.org/fhir/sid/us-npi"
}
},
"resourceType": "ExplanationOfBenefit",
"careTeam": [
{
"sequence": 2,
"provider": {
"identifier": {
"value": "999999999999999",
"system": "http://hl7.org/fhir/sid/us-npi"
}
},
"role": {
"coding": [
{
"system": "http://hl7.org/fhir/claimcareteamrole",
"code": "primary",
"display": "Primary provider"
}
]
}
}
],
"id": "dc793caf0d5817e9f930617b54fee112916ad85cb64d3aeb",
"insurance": {
"coverage": {
"reference": "Coverage/dc793caf0d58ad1fb66cbe7ba7e20b8191fe69f72524dcbc"
}
},
"type": {
"coding": [
{
"system": "https://bluebutton.cms.gov/resources/codesystem/eob-type",
"code": "PDE"
},
{
"system": "http://hl7.org/fhir/ex-claimtype",
"code": "pharmacy",
"display": "Pharmacy"
}
]
}
}