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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: Example RTPBC Response - JSON Representation

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{
  "resourceType" : "ClaimResponse",
  "id" : "rtpbc-claim-response-03",
  "meta" : {
    "profile" : [
      "http://hl7.org/fhir/us/carin-rtpbc/StructureDefinition/rtpbc-response-claimresponse"
    ]
  },
  "text" : {
    "status" : "generated",
    "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p><b>Generated Narrative</b></p><p><b>id</b>: rtpbc-claim-response-03</p><p><b>meta</b>: </p><p><b>identifier</b>: id: rtpbc-03-response</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 4:20:59 PM</p><p><b>insurer</b>: <span></span></p><p><b>request</b>: <span></span></p><p><b>outcome</b>: complete</p><p><b>disposition</b>: Processed successfully</p><blockquote><p><b>item</b></p><p><b>itemSequence</b>: 1</p><blockquote><p><b>adjudication</b></p><p><b>category</b>: <span title=\"Codes: {http://hl7.org/fhir/us/carin-rtpbc/CodeSystem/rtpbc-patient-pay-type copay}\">Copay</span></p><p><b>amount</b>: </p></blockquote><blockquote><p><b>adjudication</b></p><p><b>category</b>: <span title=\"Codes: {http://hl7.org/fhir/us/carin-rtpbc/CodeSystem/rtpbc-patient-pay-type coinsurance}\">Per prescription coinsurance</span></p><p><b>amount</b>: </p></blockquote><blockquote><p><b>adjudication</b></p><p><b>category</b>: <span title=\"Codes: {http://hl7.org/fhir/us/carin-rtpbc/CodeSystem/rtpbc-patient-pay-type total}\">Total patient responsibility</span></p><p><b>amount</b>: </p></blockquote></blockquote><blockquote><p><b>addItem</b></p><p><b>itemSequence</b>: 1</p><p><b>provider</b>: <a href=\"Organization-rtpbc-organization-03m.html\">Generated Summary: id: rtpbc-organization-03m; id: 0999029; active; <span title=\"Codes: {http://ncpdp.org/pharmacy-type M}\">Mail Order</span>; name: My Mail Service Pharmacy; ph: 5551234567</a></p><p><b>productOrService</b>: <span title=\"Codes: {http://www.nlm.nih.gov/research/umls/rxnorm 205535}\">PROzac 10 MG Oral Capsule</span></p><p><b>quantity</b>: 180 {Each}</p><h3>Adjudications</h3><table class=\"grid\"><tr><td>-</td><td><b>Category</b></td><td><b>Amount</b></td></tr><tr><td>*</td><td><span title=\"Codes: {http://hl7.org/fhir/us/carin-rtpbc/CodeSystem/rtpbc-patient-pay-type copay}\">Copay</span></td><td></td></tr><tr><td>*</td><td><span title=\"Codes: {http://hl7.org/fhir/us/carin-rtpbc/CodeSystem/rtpbc-patient-pay-type coinsurance}\">Per prescription coinsurance</span></td><td></td></tr><tr><td>*</td><td><span title=\"Codes: {http://hl7.org/fhir/us/carin-rtpbc/CodeSystem/rtpbc-patient-pay-type total}\">Total patient responsibility</span></td><td></td></tr></table></blockquote></div>"
  },
  "identifier" : [
    {
      "value" : "rtpbc-03-response"
    }
  ],
  "status" : "active",
  "type" : {
    "coding" : [
      {
        "system" : "http://terminology.hl7.org/CodeSystem/claim-type",
        "code" : "pharmacy",
        "display" : "Pharmacy"
      }
    ]
  },
  "use" : "predetermination",
  "patient" : {
    "reference" : "Patient/rtpbc-patient-03"
  },
  "created" : "2019-11-01T11:20:59-05:00",
  "insurer" : {
    "identifier" : {
      "value" : "Pharmacy Plans US"
    }
  },
  "request" : {
    "identifier" : {
      "value" : "rtpbc-03"
    }
  },
  "outcome" : "complete",
  "disposition" : "Processed successfully",
  "item" : [
    {
      "extension" : [
        {
          "url" : "http://hl7.org/fhir/us/carin-rtpbc/StructureDefinition/rtpbc-benefitRestriction",
          "valueCoding" : {
            "system" : "http://hl7.org/fhir/us/carin-rtpbc/CodeSystem/rtpbc-benefit-restriction",
            "code" : "prior-auth",
            "display" : "Prior authorization required"
          }
        }
      ],
      "itemSequence" : 1,
      "adjudication" : [
        {
          "category" : {
            "coding" : [
              {
                "system" : "http://hl7.org/fhir/us/carin-rtpbc/CodeSystem/rtpbc-patient-pay-type",
                "code" : "copay",
                "display" : "Copay"
              }
            ]
          },
          "amount" : {
            "value" : 40,
            "currency" : "USD"
          }
        },
        {
          "category" : {
            "coding" : [
              {
                "system" : "http://hl7.org/fhir/us/carin-rtpbc/CodeSystem/rtpbc-patient-pay-type",
                "code" : "coinsurance",
                "display" : "Per prescription coinsurance"
              }
            ]
          },
          "amount" : {
            "value" : 30,
            "currency" : "USD"
          }
        },
        {
          "category" : {
            "coding" : [
              {
                "system" : "http://hl7.org/fhir/us/carin-rtpbc/CodeSystem/rtpbc-patient-pay-type",
                "code" : "total",
                "display" : "Total patient responsibility"
              }
            ]
          },
          "amount" : {
            "value" : 70,
            "currency" : "USD"
          }
        }
      ]
    }
  ],
  "addItem" : [
    {
      "extension" : [
        {
          "url" : "http://hl7.org/fhir/us/carin-rtpbc/StructureDefinition/rtpbc-isAlternative",
          "valueBoolean" : true
        },
        {
          "url" : "http://hl7.org/fhir/us/carin-rtpbc/StructureDefinition/rtpbc-benefitRestriction",
          "valueCoding" : {
            "system" : "http://hl7.org/fhir/us/carin-rtpbc/CodeSystem/rtpbc-benefit-restriction",
            "code" : "covered",
            "display" : "Covered"
          }
        }
      ],
      "itemSequence" : [
        1
      ],
      "provider" : [
        {
          "reference" : "Organization/rtpbc-organization-03m"
        }
      ],
      "productOrService" : {
        "coding" : [
          {
            "system" : "http://www.nlm.nih.gov/research/umls/rxnorm",
            "code" : "205535",
            "display" : "PROzac 10 MG Oral Capsule"
          }
        ]
      },
      "quantity" : {
        "value" : 180,
        "unit" : "{Each}"
      },
      "adjudication" : [
        {
          "category" : {
            "coding" : [
              {
                "system" : "http://hl7.org/fhir/us/carin-rtpbc/CodeSystem/rtpbc-patient-pay-type",
                "code" : "copay",
                "display" : "Copay"
              }
            ]
          },
          "amount" : {
            "value" : 20,
            "currency" : "USD"
          }
        },
        {
          "category" : {
            "coding" : [
              {
                "system" : "http://hl7.org/fhir/us/carin-rtpbc/CodeSystem/rtpbc-patient-pay-type",
                "code" : "coinsurance",
                "display" : "Per prescription coinsurance"
              }
            ]
          },
          "amount" : {
            "value" : 30,
            "currency" : "USD"
          }
        },
        {
          "category" : {
            "coding" : [
              {
                "system" : "http://hl7.org/fhir/us/carin-rtpbc/CodeSystem/rtpbc-patient-pay-type",
                "code" : "total",
                "display" : "Total patient responsibility"
              }
            ]
          },
          "amount" : {
            "value" : 50,
            "currency" : "USD"
          }
        }
      ]
    }
  ]
}