01-Claim Request - Dispense
** xml and json - coming soon**
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| Bundle.entry[4].resource[0].type[0].coding[0].code[0] | public |
| Bundle.entry[4].resource[0].subscriber[0].identifier[0].system[0] | TBD.Optional |
| Bundle.entry[4].resource[0].subscriber[0].identifier[0].value[0] | 1234567891234 |
| Bundle.entry[4].resource[0].beneficiary[0].reference[0] | urn:uuid:db46f91d-f1a2-43ab-820a-03246da13580 |
| Bundle.entry[4].resource[0].relationship[0].coding[0].system[0] | http://terminology.hl7.org/CodeSystem/subscriber-relationship |
| Bundle.entry[4].resource[0].relationship[0].coding[0].code[0] | self |
| Bundle.entry[4].resource[0].payor[0].identifier[0].system[0] | tbdOptional |
| Bundle.entry[4].resource[0].payor[0].identifier[0].value[0] | 14 |
| Bundle.entry[4].resource[0].contract[0].identifier[0].system[0] | tbdOptional |
| Bundle.entry[4].resource[0].contract[0].identifier[0].value[0] | 3434343 |
| Bundle.entry[5].fullUrl[0] | urn:uuid:1f2a-4591-b09c-f4be8871431f |
| Bundle.entry[5].resource[0].id[0] | 1f2a-4591-b09c-f4be8871431f |
| Bundle.entry[5].resource[0].identifier[0].type[0].coding[0].system[0] | http://terminology.hl7.org/CodeSystem/v2-0203 |
| Bundle.entry[5].resource[0].identifier[0].type[0].coding[0].code[0] | JRX |
| Bundle.entry[5].resource[0].identifier[0].type[0].coding[0].display[0] | Jurisdictional Prescription Number |
| Bundle.entry[5].resource[0].identifier[0].system[0] | http://example.org/prescriptions |
| Bundle.entry[5].resource[0].identifier[0].value[0] | 12345689 |
| Bundle.entry[5].resource[0].identifier[1].type[0].coding[0].system[0] | http://terminology.hl7.org/CodeSystem/v2-0203 |
| Bundle.entry[5].resource[0].identifier[1].type[0].coding[0].code[0] | PrescribeIT |
| Bundle.entry[5].resource[0].identifier[1].type[0].coding[0].display[0] | PrescribeIT |
| Bundle.entry[5].resource[0].identifier[1].system[0] | http://example.org/prescriptions |
| Bundle.entry[5].resource[0].identifier[1].value[0] | 12345689 |
| Bundle.entry[5].resource[0].status[0] | active |
| Bundle.entry[5].resource[0].intent[0] | order |
| Bundle.entry[5].resource[0].medication[0].coding[0].system[0] | http://hl7.org/fhir/NamingSystem/ca-hc-din |
| Bundle.entry[5].resource[0].medication[0].coding[0].code[0] | CompoundA |
| Bundle.entry[5].resource[0].medication[0].coding[0].display[0] | PharmaSpecialOintment |
| Bundle.entry[5].resource[0].medication[0].text[0] | PharmaSpecialOintment |
| Bundle.entry[5].resource[0].subject[0].reference[0] | Patient/db46f91d-f1a2-43ab-820a-03246da13580 |
| Bundle.entry[6].fullUrl[0] | urn:uuid:db46f91d-f1a2-43ab-820a-03246da13580 |
| Bundle.entry[6].resource[0].id[0] | db46f91d-f1a2-43ab-820a-03246da13580 |
| Bundle.entry[6].resource[0].identifier[0].type[0].coding[0].system[0] | http://terminology.hl7.org/CodeSystem/v2-0203 |
| Bundle.entry[6].resource[0].identifier[0].type[0].coding[0].code[0] | PLAC |
| Bundle.entry[6].resource[0].identifier[0].system[0] | POSSystemIDTBD |
| Bundle.entry[6].resource[0].identifier[0].value[0] | 74359345 |
| Bundle.entry[6].resource[0].identifier[1].type[0].coding[0].system[0] | http://terminology.hl7.org/CodeSystem/v2-0203 |
| Bundle.entry[6].resource[0].identifier[1].type[0].coding[0].code[0] | JHN |
| Bundle.entry[6].resource[0].identifier[1].system[0] | urn:oid:2.16.840.1.113883.4.20 |
| Bundle.entry[6].resource[0].identifier[1].value[0] | 74359345 |
| Bundle.entry[6].resource[0].name[0].family[0] | Tremblant |
| Bundle.entry[6].resource[0].name[0].given[0] | Katia |
| Bundle.entry[6].resource[0].gender[0] | female |
| Bundle.entry[6].resource[0].birthDate[0] | 2018-06-23 |
| Bundle.entry[7].fullUrl[0] | urn:uuid:db46f91d-f1a2-43ab-820a-03246da15555 |
| Bundle.entry[7].resource[0].id[0] | db46f91d-f1a2-43ab-820a-03246da15555 |
| Bundle.entry[7].resource[0].contained[0].id[0] | med0319 |
| Bundle.entry[7].resource[0].contained[0].code[0].coding[0].system[0] | http://hl7.org/fhir/NamingSystem/ca-hc-din |
| Bundle.entry[7].resource[0].contained[0].code[0].coding[0].code[0] | CompoundA |
| Bundle.entry[7].resource[0].contained[0].code[0].coding[0].display[0] | PharmaSpecialOintment |
| Bundle.entry[7].resource[0].contained[0].code[0].text[0] | PharmaSpecialOintment |
| Bundle.entry[7].resource[0].contained[0].ingredient[0].extension[0].url[0] | http://pharmacyeclaims.ca/FHIR/v1.0/StructureDefinition/ext-ingredient-percentage-total-cost |
| Bundle.entry[7].resource[0].contained[0].ingredient[0].extension[0].value[0] | 35 |
| Bundle.entry[7].resource[0].contained[0].ingredient[0].extension[1].url[0] | http://pharmacyeclaims.ca/FHIR/v1.0/StructureDefinition/ext-IngredientQuantity |
| Bundle.entry[7].resource[0].contained[0].ingredient[0].extension[1].value[0].value[0] | 5 |
| Bundle.entry[7].resource[0].contained[0].ingredient[0].extension[1].value[0].unit[0] | mg |
| Bundle.entry[7].resource[0].contained[0].ingredient[0].extension[1].value[0].system[0] | http://unitsofmeasure.org |
| Bundle.entry[7].resource[0].contained[0].ingredient[0].extension[1].value[0].code[0] | mg |
| Bundle.entry[7].resource[0].contained[0].ingredient[0].item[0].coding[0].system[0] | http://hl7.org/fhir/NamingSystem/ca-hc-din |
| Bundle.entry[7].resource[0].contained[0].ingredient[0].item[0].coding[0].code[0] | 387253001 |
| Bundle.entry[7].resource[0].contained[0].ingredient[0].item[0].coding[0].display[0] | Salicyclic Acid (substance) |
| Bundle.entry[7].resource[0].contained[0].ingredient[0].strength[0].numerator[0].value[0] | 5 |
| Bundle.entry[7].resource[0].contained[0].ingredient[0].strength[0].numerator[0].system[0] | http://unitsofmeasure.org |
| Bundle.entry[7].resource[0].contained[0].ingredient[0].strength[0].numerator[0].code[0] | g |
| Bundle.entry[7].resource[0].contained[0].ingredient[0].strength[0].denominator[0].value[0] | 100 |
| Bundle.entry[7].resource[0].contained[0].ingredient[0].strength[0].denominator[0].system[0] | http://unitsofmeasure.org |
| Bundle.entry[7].resource[0].contained[0].ingredient[0].strength[0].denominator[0].code[0] | g |
| Bundle.entry[7].resource[0].contained[0].ingredient[1].extension[0].url[0] | http://pharmacyeclaims.ca/FHIR/v1.0/StructureDefinition/ext-ingredient-percentage-total-cost |
| Bundle.entry[7].resource[0].contained[0].ingredient[1].extension[0].value[0] | 65 |
| Bundle.entry[7].resource[0].contained[0].ingredient[1].extension[1].url[0] | http://pharmacyeclaims.ca/FHIR/v1.0/StructureDefinition/ext-IngredientQuantity |
| Bundle.entry[7].resource[0].contained[0].ingredient[1].extension[1].value[0].value[0] | 5 |
| Bundle.entry[7].resource[0].contained[0].ingredient[1].extension[1].value[0].unit[0] | mg |
| Bundle.entry[7].resource[0].contained[0].ingredient[1].extension[1].value[0].system[0] | http://unitsofmeasure.org |
| Bundle.entry[7].resource[0].contained[0].ingredient[1].extension[1].value[0].code[0] | mg |
| Bundle.entry[7].resource[0].contained[0].ingredient[1].item[0].coding[0].system[0] | http://hl7.org/fhir/NamingSystem/OtherCompoundSubstance |
| Bundle.entry[7].resource[0].contained[0].ingredient[1].item[0].coding[0].code[0] | 4545452 |
| Bundle.entry[7].resource[0].contained[0].ingredient[1].item[0].coding[0].display[0] | White Petrolatum (substance) |
| Bundle.entry[7].resource[0].contained[0].ingredient[1].strength[0].numerator[0].value[0] | 1 |
| Bundle.entry[7].resource[0].contained[0].ingredient[1].strength[0].numerator[0].system[0] | http://unitsofmeasure.org |
| Bundle.entry[7].resource[0].contained[0].ingredient[1].strength[0].numerator[0].code[0] | g |
| Bundle.entry[7].resource[0].contained[0].ingredient[1].strength[0].denominator[0].value[0] | 100 |
| Bundle.entry[7].resource[0].contained[0].ingredient[1].strength[0].denominator[0].system[0] | http://unitsofmeasure.org |
| Bundle.entry[7].resource[0].contained[0].ingredient[1].strength[0].denominator[0].code[0] | g |
| Bundle.entry[7].resource[0].extension[0].url[0] | http://pharmacyeclaims.ca/FHIR/v1.0/StructureDefinition/ext-RenderedDosageInstruction |
| Bundle.entry[7].resource[0].extension[0].value[0] | Take 1 tablet by mouth twice daily. Take with food. Take after meals. |
| Bundle.entry[7].resource[0].status[0] | completed |
| Bundle.entry[7].resource[0].medication[0].reference[0] | #med0319 |
| Bundle.entry[7].resource[0].performer[0].actor[0].identifier[0].system[0] | http://pharmacyeclaims.ca/FHIR/ValueSet/pharmacist-licence-identifier-system |
| Bundle.entry[7].resource[0].performer[0].actor[0].identifier[0].value[0] | 123456 |
| Bundle.entry[7].resource[0].type[0].coding[0].system[0] | http://terminology.hl7.org/CodeSystem/v3-ActCode |
| Bundle.entry[7].resource[0].type[0].coding[0].code[0] | RFP |
| Bundle.entry[7].resource[0].type[0].coding[0].display[0] | Refill - Part Fill |
| Bundle.entry[7].resource[0].quantity[0].value[0] | 30 |
| Bundle.entry[7].resource[0].quantity[0].system[0] | http://unitsofmeasure.org |
| Bundle.entry[7].resource[0].quantity[0].code[0] | g |
| Bundle.entry[7].resource[0].daysSupply[0].value[0] | 10 |
| Bundle.entry[7].resource[0].daysSupply[0].unit[0] | Day |
| Bundle.entry[7].resource[0].daysSupply[0].system[0] | http://unitsofmeasure.org |
| Bundle.entry[7].resource[0].daysSupply[0].code[0] | d |
| Bundle.entry[7].resource[0].substitution[0].wasSubstituted[0] | False |
| Bundle.entry[7].resource[0].substitution[0].reason[0].coding[0].system[0] | http://terminology.hl7.org/CodeSystem/v3-ActReason |
| Bundle.entry[7].resource[0].substitution[0].reason[0].coding[0].code[0] | 1 |
| Bundle.entry[7].resource[0].substitution[0].reason[0].coding[0].display[0] | prescriber's choice |
| Bundle.entry[8].fullUrl[0] | urn:uuid:db46f91d-f1a2-43ab-820a-666615555 |
| Bundle.entry[8].resource[0].id[0] | db46f91d-f1a2-43ab-820a-666615555 |
| Bundle.entry[8].resource[0].status[0] | active |
| Bundle.entry[8].resource[0].type[0].coding[0].system[0] | http://terminology.hl7.org/CodeSystem/claim-type |
| Bundle.entry[8].resource[0].type[0].coding[0].code[0] | pharmacy |
| Bundle.entry[8].resource[0].subType[0].coding[0].system[0] | http://pharmacyeclaims.ca/FHIR/CodeSystem/claim-response-subType |
| Bundle.entry[8].resource[0].subType[0].coding[0].code[0] | privateEHCPOL |
| Bundle.entry[8].resource[0].use[0] | claim |
| Bundle.entry[8].resource[0].patient[0].reference[0] | urn:uuid:db46f91d-f1a2-43ab-820a-03246da13580 |
| Bundle.entry[8].resource[0].created[0] | 2014-08-16 |
| Bundle.entry[8].resource[0].insurer[0].identifier[0].system[0] | http://pharmacyeclaims.ca/FHIR/CPHA-identifier/IIN |
| Bundle.entry[8].resource[0].insurer[0].identifier[0].value[0] | 11 |
| Bundle.entry[8].resource[0].request[0].reference[0] | urn:uuid:primaryclaimrequstid |
| Bundle.entry[8].resource[0].outcome[0] | complete |
| Bundle.entry[8].resource[0].disposition[0] | B |
| Bundle.entry[8].resource[0].payeeType[0].coding[0].system[0] | http://terminology.hl7.org/CodeSystem/payeetype |
| Bundle.entry[8].resource[0].payeeType[0].coding[0].code[0] | provider |
| Bundle.entry[8].resource[0].item[0].itemSequence[0] | 1 |
| Bundle.entry[8].resource[0].item[0].adjudication[0].category[0].coding[0].code[0] | Co-pay |
| Bundle.entry[8].resource[0].item[0].adjudication[0].amount[0].value[0] | 12.00 |
| Bundle.entry[8].resource[0].item[1].itemSequence[0] | 2 |
| Bundle.entry[8].resource[0].item[1].adjudication[0].category[0].coding[0].code[0] | Deductible |
| Bundle.entry[8].resource[0].item[1].adjudication[0].amount[0].value[0] | 0.00 |
| Bundle.entry[8].resource[0].item[2].itemSequence[0] | 3 |
| Bundle.entry[8].resource[0].item[2].adjudication[0].category[0].coding[0].code[0] | CoInsurance |
| Bundle.entry[8].resource[0].item[2].adjudication[0].amount[0].value[0] | 0.00 |
| Bundle.entry[8].resource[0].item[3].itemSequence[0] | 4 |
| Bundle.entry[8].resource[0].item[3].adjudication[0].category[0].coding[0].code[0] | DrugCost |
| Bundle.entry[8].resource[0].item[3].adjudication[0].amount[0].value[0] | 40.00 |
| Bundle.entry[8].resource[0].item[4].itemSequence[0] | 5 |
| Bundle.entry[8].resource[0].item[4].adjudication[0].category[0].coding[0].code[0] | Upcharge |
| Bundle.entry[8].resource[0].item[4].adjudication[0].amount[0].value[0] | 5.00 |
| Bundle.entry[8].resource[0].item[5].itemSequence[0] | 6 |
| Bundle.entry[8].resource[0].item[5].adjudication[0].category[0].coding[0].code[0] | GenericIncentive |
| Bundle.entry[8].resource[0].item[5].adjudication[0].amount[0].value[0] | 5.00 |
| Bundle.entry[8].resource[0].item[6].itemSequence[0] | 8 |
| Bundle.entry[8].resource[0].item[6].adjudication[0].category[0].coding[0].code[0] | ProfFee |
| Bundle.entry[8].resource[0].item[6].adjudication[0].amount[0].value[0] | 9.00 |
| Bundle.entry[8].resource[0].item[7].itemSequence[0] | 9 |
| Bundle.entry[8].resource[0].item[7].adjudication[0].category[0].coding[0].code[0] | CompoundingCharge |
| Bundle.entry[8].resource[0].item[7].adjudication[0].amount[0].value[0] | 9.00 |
| Bundle.entry[8].resource[0].item[8].itemSequence[0] | 10 |
| Bundle.entry[8].resource[0].item[8].adjudication[0].category[0].coding[0].code[0] | SSF |
| Bundle.entry[8].resource[0].item[8].adjudication[0].amount[0].value[0] | 2.00 |
| Bundle.entry[8].resource[0].item[9].itemSequence[0] | 11 |
| Bundle.entry[8].resource[0].item[9].adjudication[0].category[0].coding[0].code[0] | ResponseCode |
| Bundle.entry[8].resource[0].item[9].adjudication[0].reason[0].coding[0].system[0] | http://terminology.hl7.org/CodeSystem/adjudication-reason |
| Bundle.entry[8].resource[0].item[9].adjudication[0].reason[0].coding[0].code[0] | ar002 |
| Bundle.entry[8].resource[0].item[9].adjudication[0].reason[0].coding[0].display[0] | Optional display |
| Bundle.entry[8].resource[0].item[9].adjudication[0].amount[0].value[0] | 1.00 |
| Bundle.entry[8].resource[0].item[10].itemSequence[0] | 11 |
| Bundle.entry[8].resource[0].item[10].adjudication[0].category[0].coding[0].code[0] | ResponseCode |
| Bundle.entry[8].resource[0].item[10].adjudication[0].reason[0].coding[0].system[0] | http://terminology.hl7.org/CodeSystem/adjudication-reason |
| Bundle.entry[8].resource[0].item[10].adjudication[0].reason[0].coding[0].code[0] | ar002 |
| Bundle.entry[8].resource[0].item[10].adjudication[0].reason[0].coding[0].display[0] | Optional display |
| Bundle.entry[8].resource[0].payment[0].type[0].coding[0].system[0] | http://terminology.hl7.org/CodeSystem/ex-paymenttype |
| Bundle.entry[8].resource[0].payment[0].type[0].coding[0].code[0] | complete |
| Bundle.entry[8].resource[0].payment[0].date[0] | 2025-06-29 |
| Bundle.entry[8].resource[0].payment[0].amount[0].value[0] | 100.47 |
| Bundle.entry[8].resource[0].processNote[0].number[0] | 1 |
| Bundle.entry[8].resource[0].processNote[0].type[0] | display |
| Bundle.entry[8].resource[0].processNote[0].text[0] | First adjudicator note |
| Bundle.entry[8].resource[0].processNote[0].language[0].coding[0].system[0] | urn:ietf:bcp:47 |
| Bundle.entry[8].resource[0].processNote[0].language[0].coding[0].code[0] | en-CA |
| Bundle.entry[8].resource[0].processNote[0].language[0].text[0] | unknown |
| Bundle.entry[8].resource[0].processNote[1].number[0] | 2 |
| Bundle.entry[8].resource[0].processNote[1].type[0] | display |
| Bundle.entry[8].resource[0].processNote[1].text[0] | Second adjudicator note |
| Bundle.entry[8].resource[0].processNote[1].language[0].coding[0].system[0] | urn:ietf:bcp:47 |
| Bundle.entry[8].resource[0].processNote[1].language[0].coding[0].code[0] | en-CA |