This page is part of the Consumer Real-time Pharmacy Benefit Check (v1.0.0: STU 1) based on FHIR R4. This is the current published version. For a full list of available versions, see the Directory of published versions

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: RTPBC Request to a Pricing Source - XML Representation

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<Claim xmlns="http://hl7.org/fhir">
  <id value="rtpbc-claim-03-price-source"/>
  <meta>
    <profile
             value="http://hl7.org/fhir/us/carin-rtpbc/StructureDefinition/rtpbc-request-claim"/>
  </meta>
  <text>
    <status value="generated"/>
    <div xmlns="http://www.w3.org/1999/xhtml"><p><b>Generated Narrative</b></p><p><b>id</b>: rtpbc-claim-03-price-source</p><p><b>meta</b>: </p><p><b>identifier</b>: id: rtpbc-03</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>: <a href="Patient-rtpbc-patient-03.html">Generated Summary: id: rtpbc-patient-03; Patient internal identifier: 30455; Jane Doe ; gender: female; birthDate: 1975-12-05</a></p><p><b>created</b>: Nov 1, 2019 4:20:54 PM</p><p><b>provider</b>: <a href="Organization-rtpbc-organization-03.html">Generated Summary: id: rtpbc-organization-03; id: 0999017; active; <span title="Codes: {http://ncpdp.org/pharmacy-type R}">Retail</span>; name: Hometown Drug; ph: 6081234567</a></p><p><b>priority</b>: <span title="Codes: {http://terminology.hl7.org/CodeSystem/processpriority normal}">Normal</span></p><p><b>prescription</b>: <a href="MedicationRequest-rtpbc-medicationrequest-03.html">Generated Summary: id: rtpbc-medicationrequest-03; status: draft; intent: proposal; reported; <span title="Codes: {http://www.nlm.nih.gov/research/umls/rxnorm 205535}">PROzac 10 MG Oral Capsule</span>; authoredOn: 2019-11-01</a></p><h3>CareTeams</h3><table class="grid"><tr><td>-</td><td><b>Sequence</b></td><td><b>Provider</b></td></tr><tr><td>*</td><td>1</td><td><a href="Practitioner-rtpbc-practitioner-03.html">Generated Summary: id: rtpbc-practitioner-03; id: 1234567890; Johnson </a></td></tr></table><h3>Insurances</h3><table class="grid"><tr><td>-</td><td><b>Sequence</b></td><td><b>Focal</b></td><td><b>Coverage</b></td></tr><tr><td>*</td><td>1</td><td>true</td><td><span></span></td></tr></table><h3>Items</h3><table class="grid"><tr><td>-</td><td><b>Sequence</b></td><td><b>CareTeamSequence</b></td><td><b>ProductOrService</b></td><td><b>Quantity</b></td></tr><tr><td>*</td><td>1</td><td>1</td><td><span title="Codes: {http://www.nlm.nih.gov/research/umls/rxnorm 205535}">PROzac 10 MG Oral Capsule</span></td><td>60 {Each}</td></tr></table></div>
  </text>
  <identifier>
    <value value="rtpbc-03"/>
  </identifier>
  <status value="active"/>
  <type>
    <coding>
      <system value="http://terminology.hl7.org/CodeSystem/claim-type"/>
      <code value="pharmacy"/>
      <display value="Pharmacy"/>
    </coding>
  </type>
  <use value="predetermination"/>
  <patient>
    <reference value="Patient/rtpbc-patient-03"/>
  </patient>
  <created value="2019-11-01T11:20:54-05:00"/>
  <provider>
    <reference value="Organization/rtpbc-organization-03"/>
  </provider>
  <priority>
    <coding>
      <system value="http://terminology.hl7.org/CodeSystem/processpriority"/>
      <code value="normal"/>
      <display value="Normal"/>
    </coding>
  </priority>
  <prescription>
    <reference value="MedicationRequest/rtpbc-medicationrequest-03"/>
  </prescription>
  <careTeam>
    <sequence value="1"/>
    <provider>
      <reference value="Practitioner/rtpbc-practitioner-03"/>
    </provider>
  </careTeam>
  <insurance>
    <sequence value="1"/>
    <focal value="true"/>
    <coverage>
      <identifier>
        <value value="GOODPRICING"/>
      </identifier>
    </coverage>
  </insurance>
  <item>
    <sequence value="1"/>
    <careTeamSequence value="1"/>
    <productOrService>
      <coding>
        <system value="http://www.nlm.nih.gov/research/umls/rxnorm"/>
        <code value="205535"/>
        <display value="PROzac 10 MG Oral Capsule"/>
      </coding>
    </productOrService>
    <quantity>
      <value value="60"/>
      <unit value="{Each}"/>
    </quantity>
  </item>
</Claim>