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
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: claim-chargeback-001 - XML Representation

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<Claim xmlns="http://hl7.org/fhir">
  <id value="claim-chargeback-001"/>
  <meta>
    <profile
             value="https://exchange.example.org/fhir/ig/340b-exchange/StructureDefinition/340b-claim"/>
  </meta>
  <text>
    <status value="extensions"/>
    <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>
  </text>
  <extension
             url="https://exchange.example.org/fhir/ig/340b-exchange/StructureDefinition/340b-correlation-id">
    <valueString value="corr-cb-7721"/>
  </extension>
  <extension
             url="https://exchange.example.org/fhir/ig/340b-exchange/StructureDefinition/340b-exchange-transaction-id">
    <valueString value="tx-cb-7721"/>
  </extension>
  <extension
             url="https://exchange.example.org/fhir/ig/340b-exchange/StructureDefinition/340b-rule-set-version">
    <valueString value="1.2.0"/>
  </extension>
  <extension
             url="https://exchange.example.org/fhir/ig/340b-exchange/StructureDefinition/340b-chargeback-reference">
    <valueIdentifier>
      <system value="https://exchange.example.org/chargeback"/>
      <value value="cb-7721"/>
    </valueIdentifier>
  </extension>
  <identifier>
    <system value="https://exchange.example.org/claim-ids"/>
    <value value="claim-7721"/>
  </identifier>
  <status value="active"/>
  <type>
    <coding>
      <system value="http://terminology.hl7.org/CodeSystem/claim-type"/>
      <code value="pharmacy"/>
    </coding>
  </type>
  <use value="claim"/>
  <patient>🔗 
    <reference value="Patient/p-001"/>
  </patient>
  <created value="2026-04-24"/>
  <insurer>🔗 
    <reference value="Organization/manufacturer-77"/>
  </insurer>
  <provider>🔗 
    <reference value="Organization/pharmacy-22"/>
  </provider>
  <priority>
    <coding>
      <system value="http://terminology.hl7.org/CodeSystem/processpriority"/>
      <code value="normal"/>
    </coding>
  </priority>
  <insurance>
    <sequence value="1"/>
    <focal value="true"/>
    <coverage>🔗 
      <reference value="Coverage/cov-001"/>
    </coverage>
  </insurance>
  <item>
    <sequence value="1"/>
    <productOrService>
      <coding>
        <system value="http://example.org/drug-codes"/>
        <code value="00000-1111-22"/>
      </coding>
    </productOrService>
  </item>
</Claim>