HL7.FHIR.US.CARIN-RTPBC\Example RTPBC Response - not covered - XML Representation

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
: Example RTPBC Response - not covered - XML Representation

Raw xml | Download

<ClaimResponse xmlns="http://hl7.org/fhir">
  <id value="rtpbc-claim-response-not-covered"/>
  <meta>
    <profile
             value="http://hl7.org/fhir/us/carin-rtpbc/StructureDefinition/rtpbc-response-claimresponse"/>
  </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-response-not-covered</p><p><b>meta</b>: </p><p><b>identifier</b>: id: rtpbc-03-response-c-r</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><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 eligible}">Eligible amount</span></td><td></td></tr></table></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 1734642}">Zepatier 50 MG / 100 MG Oral Tablet</span></p><p><b>quantity</b>: 28 {Each}</p><p><b>noteNumber</b>: 1</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><h3>ProcessNotes</h3><table class="grid"><tr><td>-</td><td><b>Number</b></td><td><b>Text</b></td></tr><tr><td>*</td><td>1</td><td>Quantity limit: 28 tablets per month</td></tr></table></div>
  </text>
  <identifier>
    <value value="rtpbc-03-response-c-r"/>
  </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="2019-11-01T11:20:59-05:00"/>
  <insurer>
    <identifier>
      <value value="Pharmacy Plans US"/>
    </identifier>
  </insurer>
  <request>
    <identifier>
      <value value="rtpbc-03"/>
    </identifier>
  </request>
  <outcome value="complete"/>
  <disposition value="Processed successfully"/>
  <item>
    <extension
               url="http://hl7.org/fhir/us/carin-rtpbc/StructureDefinition/rtpbc-benefitRestriction">
      <valueCoding>
        <system
                value="http://hl7.org/fhir/us/carin-rtpbc/CodeSystem/rtpbc-benefit-restriction"/>
        <code value="not-covered"/>
        <display value="Not covered"/>
      </valueCoding>
    </extension>
    <itemSequence value="1"/>
    <adjudication>
      <category>
        <coding>
          <system
                  value="http://hl7.org/fhir/us/carin-rtpbc/CodeSystem/rtpbc-patient-pay-type"/>
          <code value="eligible"/>
          <display value="Eligible amount"/>
        </coding>
      </category>
      <amount>
        <value value="0"/>
        <currency value="USD"/>
      </amount>
    </adjudication>
  </item>
  <addItem>
    <extension
               url="http://hl7.org/fhir/us/carin-rtpbc/StructureDefinition/rtpbc-isAlternative">
      <valueBoolean value="true"/>
    </extension>
    <extension
               url="http://hl7.org/fhir/us/carin-rtpbc/StructureDefinition/rtpbc-benefitRestriction">
      <valueCoding>
        <system
                value="http://hl7.org/fhir/us/carin-rtpbc/CodeSystem/rtpbc-benefit-restriction"/>
        <code value="prior-auth"/>
        <display value="Prior authorization required"/>
      </valueCoding>
    </extension>
    <extension
               url="http://hl7.org/fhir/us/carin-rtpbc/StructureDefinition/rtpbc-benefitRestriction">
      <valueCoding>
        <system
                value="http://hl7.org/fhir/us/carin-rtpbc/CodeSystem/rtpbc-benefit-restriction"/>
        <code value="quantity-limit"/>
        <display value="Quantity limit applies"/>
      </valueCoding>
    </extension>
    <itemSequence value="1"/>
    <provider>
      <reference value="Organization/rtpbc-organization-03m"/>
    </provider>
    <productOrService>
      <coding>
        <system value="http://www.nlm.nih.gov/research/umls/rxnorm"/>
        <code value="1734642"/>
        <display value="Zepatier 50 MG / 100 MG Oral Tablet"/>
      </coding>
    </productOrService>
    <quantity>
      <value value="28"/>
      <unit value="{Each}"/>
    </quantity>
    <noteNumber value="1"/>
    <adjudication>
      <category>
        <coding>
          <system
                  value="http://hl7.org/fhir/us/carin-rtpbc/CodeSystem/rtpbc-patient-pay-type"/>
          <code value="copay"/>
          <display value="Copay"/>
        </coding>
      </category>
      <amount>
        <value value="405"/>
        <currency value="USD"/>
      </amount>
    </adjudication>
    <adjudication>
      <category>
        <coding>
          <system
                  value="http://hl7.org/fhir/us/carin-rtpbc/CodeSystem/rtpbc-patient-pay-type"/>
          <code value="coinsurance"/>
          <display value="Per prescription coinsurance"/>
        </coding>
      </category>
      <amount>
        <value value="469"/>
        <currency value="USD"/>
      </amount>
    </adjudication>
    <adjudication>
      <category>
        <coding>
          <system
                  value="http://hl7.org/fhir/us/carin-rtpbc/CodeSystem/rtpbc-patient-pay-type"/>
          <code value="total"/>
          <display value="Total patient responsibility"/>
        </coding>
      </category>
      <amount>
        <value value="874"/>
        <currency value="USD"/>
      </amount>
    </adjudication>
  </addItem>
  <processNote>
    <number value="1"/>
    <text value="Quantity limit: 28 tablets per month"/>
  </processNote>
</ClaimResponse>