340B FHIR Exchange Implementation Guide - Local Development build (v0.1.0-ballot) built by the FHIR (HL7® FHIR® Standard) Build Tools. See the Directory of published versions

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• XML
• JSON
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: claim-chargeback-001 - JSON Representation

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{
  "resourceType" : "Claim",
  "id" : "claim-chargeback-001",
  "meta" : {
    "profile" : [
      🔗 "https://exchange.example.org/fhir/ig/340b-exchange/StructureDefinition/340b-claim"
    ]
  },
  "text" : {
    "status" : "extensions",
    "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p class=\"res-header-id\"><b>Generated Narrative: Claim claim-chargeback-001</b></p><a name=\"claim-chargeback-001\"> </a><a name=\"hcclaim-chargeback-001\"> </a><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\"/><p style=\"margin-bottom: 0px\">Profile: <a href=\"StructureDefinition-340b-claim.html\">340B Claim Profile</a></p></div><p><b>340B Correlation ID Extension</b>: corr-cb-7721</p><p><b>340B Exchange Transaction ID Extension</b>: tx-cb-7721</p><p><b>340B Rule Set Version Extension</b>: 1.2.0</p><p><b>340B Chargeback Reference Extension</b>: <code>https://exchange.example.org/chargeback</code>/cb-7721</p><p><b>identifier</b>: <code>https://exchange.example.org/claim-ids</code>/claim-7721</p><p><b>status</b>: Active</p><p><b>type</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/claim-type pharmacy}\">Pharmacy</span></p><p><b>use</b>: Claim</p><p><b>patient</b>: <a href=\"Patient-p-001.html\">Pat Example  (no stated gender), DoB Unknown</a></p><p><b>created</b>: 2026-04-24</p><p><b>insurer</b>: <a href=\"Organization-manufacturer-77.html\">Organization Example Manufacturer 77</a></p><p><b>provider</b>: <a href=\"Organization-pharmacy-22.html\">Organization Example Pharmacy 22</a></p><p><b>priority</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/processpriority normal}\">Normal</span></p><h3>Insurances</h3><table class=\"grid\"><tr><td style=\"display: none\">-</td><td><b>Sequence</b></td><td><b>Focal</b></td><td><b>Coverage</b></td></tr><tr><td style=\"display: none\">*</td><td>1</td><td>true</td><td><a href=\"Coverage-cov-001.html\">Coverage: status = active</a></td></tr></table><h3>Items</h3><table class=\"grid\"><tr><td style=\"display: none\">-</td><td><b>Sequence</b></td><td><b>ProductOrService</b></td></tr><tr><td style=\"display: none\">*</td><td>1</td><td><span title=\"Codes:{http://example.org/drug-codes 00000-1111-22}\">00000-1111-22</span></td></tr></table></div>"
  },
  "extension" : [
    {
      "url" : "https://exchange.example.org/fhir/ig/340b-exchange/StructureDefinition/340b-correlation-id",
      "valueString" : "corr-cb-7721"
    },
    {
      "url" : "https://exchange.example.org/fhir/ig/340b-exchange/StructureDefinition/340b-exchange-transaction-id",
      "valueString" : "tx-cb-7721"
    },
    {
      "url" : "https://exchange.example.org/fhir/ig/340b-exchange/StructureDefinition/340b-rule-set-version",
      "valueString" : "1.2.0"
    },
    {
      "url" : "https://exchange.example.org/fhir/ig/340b-exchange/StructureDefinition/340b-chargeback-reference",
      "valueIdentifier" : {
        "system" : "https://exchange.example.org/chargeback",
        "value" : "cb-7721"
      }
    }
  ],
  "identifier" : [
    {
      "system" : "https://exchange.example.org/claim-ids",
      "value" : "claim-7721"
    }
  ],
  "status" : "active",
  "type" : {
    "coding" : [
      {
        "system" : "http://terminology.hl7.org/CodeSystem/claim-type",
        "code" : "pharmacy"
      }
    ]
  },
  "use" : "claim",
  "patient" : {
    🔗 "reference" : "Patient/p-001"
  },
  "created" : "2026-04-24",
  "insurer" : {
    🔗 "reference" : "Organization/manufacturer-77"
  },
  "provider" : {
    🔗 "reference" : "Organization/pharmacy-22"
  },
  "priority" : {
    "coding" : [
      {
        "system" : "http://terminology.hl7.org/CodeSystem/processpriority",
        "code" : "normal"
      }
    ]
  },
  "insurance" : [
    {
      "sequence" : 1,
      "focal" : true,
      "coverage" : {
        🔗 "reference" : "Coverage/cov-001"
      }
    }
  ],
  "item" : [
    {
      "sequence" : 1,
      "productOrService" : {
        "coding" : [
          {
            "system" : "http://example.org/drug-codes",
            "code" : "00000-1111-22"
          }
        ]
      }
    }
  ]
}