RTPBC ClaimResponse - requested drug is not covered

In this example:

• the requested medication is not covered by the patient's plan. The Benefit Restriction contains a value of "not-covered" and the adjucation shows an eligible amount of zero dollars.
• the addItem contains an alternative drug that is covered, but with a requirement for prior authorziation and a quantity limit. Details of the quantity limit are conveyed in the processNote element.

Generated Narrative

id: rtpbc-claim-response-not-covered

meta:

identifier: id: rtpbc-03-response-c-r

status: active

type: Pharmacy

use: predetermination

patient: Generated Summary: id: rtpbc-patient-03; Patient internal identifier: 30455; Jane Doe ; gender: female; birthDate: 1975-12-05

created: Nov 1, 2019 4:20:59 PM

insurer:

request:

outcome: complete

disposition: Processed successfully

item

itemSequence: 1

Adjudications

-	Category	Amount
*	Eligible amount

addItem

itemSequence: 1

provider: Generated Summary: id: rtpbc-organization-03m; id: 0999029; active; Mail Order; name: My Mail Service Pharmacy; ph: 5551234567

productOrService: Zepatier 50 MG / 100 MG Oral Tablet

quantity: 28 {Each}

noteNumber: 1

Adjudications

-	Category	Amount
*	Copay
*	Per prescription coinsurance
*	Total patient responsibility

ProcessNotes