{
  "resourceType" : "Claim",
  "id" : "rtpbc-claim-non-phi-2",
  "meta" : {
    "profile" : ["http://hl7.org/fhir/us/carin-rtpbc/StructureDefinition/rtpbc-request-claim-non-phi"]
  },
  "language" : "en",
  "text" : {
    "status" : "generated",
    "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\" xml:lang=\"en\" lang=\"en\"><p class=\"res-header-id\"><b>Generated Narrative: Claim rtpbc-claim-non-phi-2</b></p><a name=\"rtpbc-claim-non-phi-2\"> </a><a name=\"hcrtpbc-claim-non-phi-2\"> </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\">Language: en</p><p style=\"margin-bottom: 0px\">Profile: <a href=\"StructureDefinition-rtpbc-request-claim-non-phi.html\">RTPBC Request Using Claim - Non-PHI</a></p></div><p><b>identifier</b>: rtpbc-claim-non-phi-2</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>: Predetermination</p><p><b>patient</b>: ?rref?</p><p><b>created</b>: 2025-11-01 11:20:54-0500</p><p><b>provider</b>: <a href=\"Organization-rtpbc-organization-01.html\">Organization Hometown Drug</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>false</td><td>?rref?</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><td><b>Quantity</b></td></tr><tr><td style=\"display: none\">*</td><td>1</td><td><span title=\"Codes:{http://www.nlm.nih.gov/research/umls/rxnorm 205535}\">Prozac 10mg Capsule</span></td><td>60 {Each}</td></tr></table></div>"
  },
  "identifier" : [{
    "value" : "rtpbc-claim-non-phi-2"
  }],
  "status" : "active",
  "type" : {
    "coding" : [{
      "system" : "http://terminology.hl7.org/CodeSystem/claim-type",
      "code" : "pharmacy",
      "display" : "Pharmacy"
    }]
  },
  "use" : "predetermination",
  "patient" : {
    "extension" : [{
      "url" : "http://hl7.org/fhir/StructureDefinition/data-absent-reason",
      "valueCode" : "masked"
    }]
  },
  "created" : "2025-11-01T11:20:54-05:00",
  "provider" : {
    "reference" : "Organization/rtpbc-organization-01"
  },
  "priority" : {
    "coding" : [{
      "system" : "http://terminology.hl7.org/CodeSystem/processpriority",
      "code" : "normal",
      "display" : "Normal"
    }]
  },
  "insurance" : [{
    "sequence" : 1,
    "focal" : false,
    "coverage" : {
      "extension" : [{
        "url" : "http://hl7.org/fhir/StructureDefinition/data-absent-reason",
        "valueCode" : "masked"
      }]
    }
  }],
  "item" : [{
    "sequence" : 1,
    "productOrService" : {
      "coding" : [{
        "system" : "http://www.nlm.nih.gov/research/umls/rxnorm",
        "code" : "205535",
        "display" : "fluoxetine 10 MG Oral Capsule [Prozac]"
      }],
      "text" : "Prozac 10mg Capsule"
    },
    "quantity" : {
      "value" : 60,
      "unit" : "{Each}"
    }
  }]
}