HL7.FHIR.US.CARIN-RTPBC\Example RTPBC Response Bundle - 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 in it's permanent home (it will always be available at this URL). For a full list of available versions, see the Directory of published versions
: Example RTPBC Response Bundle - XML Representation

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<Bundle xmlns="http://hl7.org/fhir">
  <id value="rtpbc-bundle-response-03-w-header"/>
  <meta>
    <profile
             value="http://hl7.org/fhir/us/carin-rtpbc/StructureDefinition/rtpbc-response-bundle"/>
  </meta>
  <type value="message"/>
  <timestamp value="2019-11-15T13:10:15-05:00"/>
  <entry>
    <fullUrl value="urn:uuid:61ebe359-bfdc-4613-8bf2-c5e300945f0a"/>
    <resource>
      <MessageHeader>
        <id value="rtpbc-messageheader-response-03"/>
        <meta>
          <profile
                   value="http://hl7.org/fhir/us/carin-rtpbc/StructureDefinition/rtpbc-response-messageheader"/>
        </meta>
        <text>
          <status value="generated"/>
          <div xmlns="http://www.w3.org/1999/xhtml"><p><b>Generated Narrative</b></p><p><b>id</b>: rtpbc-messageheader-response-03</p><p><b>meta</b>: </p><p><b>event</b>: <span title="{http://hl7.org/fhir/us/carin-rtpbc/CodeSystem/rtpbc-event-type rtpbc-response}">RTPBC Response</span></p><h3>Sources</h3><table class="grid"><tr><td>-</td><td><b>Name</b></td><td><b>Endpoint</b></td></tr><tr><td>*</td><td>PharmacyBenefitsCompany</td><td><a href="http://example.org/PharmacyBenefitsCo/fhir">http://example.org/PharmacyBenefitsCo/fhir</a></td></tr></table><h3>Responses</h3><table class="grid"><tr><td>-</td><td><b>Identifier</b></td><td><b>Code</b></td></tr><tr><td>*</td><td>rtpbc-messageheader-request-03</td><td>ok</td></tr></table><p><b>focus</b>: <a href="#ClaimResponse_rtpbc-claim-response-03">See above (ClaimResponse/rtpbc-claim-response-03)</a></p><p><b>definition</b>: <a href="http://hl7.org/fhir/us/carin-rtpbc/MessageDefinition/rtpbc-response">http://hl7.org/fhir/us/carin-rtpbc/MessageDefinition/rtpbc-response</a></p></div>
        </text>
        <eventCoding>
          <system
                  value="http://hl7.org/fhir/us/carin-rtpbc/CodeSystem/rtpbc-event-type"/>
          <code value="rtpbc-response"/>
          <display value="RTPBC Response"/>
        </eventCoding>
        <source>
          <name value="PharmacyBenefitsCompany"/>
          <endpoint value="http://example.org/PharmacyBenefitsCo/fhir"/>
        </source>
        <response>
          <identifier value="rtpbc-messageheader-request-03"/>
          <code value="ok"/>
        </response>
        <focus>
          <reference value="urn:uuid:61ebe359-bfdc-4613-8bf2-c5e3464805f0b"/>
        </focus>
        <definition
                    value="http://hl7.org/fhir/us/carin-rtpbc/MessageDefinition/rtpbc-response"/>
      </MessageHeader>
    </resource>
  </entry>
  <entry>
    <fullUrl value="urn:uuid:61ebe359-bfdc-4613-8bf2-c5e3464805f0b"/>
    <resource>
      <ClaimResponse>
        <id value="rtpbc-claim-response-03"/>
        <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-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">See above (Patient/rtpbc-patient-03)</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">See above (Organization/rtpbc-organization-03m)</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>
        </text>
        <identifier>
          <value value="rtpbc-03-response"/>
        </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="prior-auth"/>
              <display value="Prior authorization required"/>
            </valueCoding>
          </extension>
          <itemSequence 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="40"/>
              <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="30"/>
              <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="70"/>
              <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="covered"/>
              <display value="Covered"/>
            </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="205535"/>
              <display value="PROzac 10 MG Oral Capsule"/>
            </coding>
          </productOrService>
          <quantity>
            <value value="180"/>
            <unit value="{Each}"/>
          </quantity>
          <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="20"/>
              <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="30"/>
              <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="50"/>
              <currency value="USD"/>
            </amount>
          </adjudication>
        </addItem>
      </ClaimResponse>
    </resource>
  </entry>
  <entry>
    <fullUrl value="urn:uuid:61ebe359-bfdc-4613-8bf2-c5e300945f0c"/>
    <resource>
      <Patient>
        <id value="rtpbc-patient-03"/>
        <meta>
          <profile
                   value="http://hl7.org/fhir/us/carin-rtpbc/StructureDefinition/rtpbc-patient"/>
        </meta>
        <text>
          <status value="generated"/>
          <div xmlns="http://www.w3.org/1999/xhtml"><p><b>Generated Narrative</b></p><p><b>id</b>: rtpbc-patient-03</p><p><b>meta</b>: </p><p><b>identifier</b>: Patient internal identifier: 30455</p><p><b>name</b>: Jane Doe </p><p><b>gender</b>: female</p><p><b>birthDate</b>: 1975-12-05</p><p><b>address</b>: 100 Oak Court Madison WI 53510 US </p></div>
        </text>
        <identifier>
          <type>
            <coding>
              <system value="http://terminology.hl7.org/CodeSystem/v2-0203"/>
              <code value="PI"/>
              <display value="Patient internal identifier"/>
            </coding>
            <text value="Patient internal identifier"/>
          </type>
          <system value="http://example.org/MyPatientApp"/>
          <value value="30455"/>
        </identifier>
        <name>
          <family value="Doe"/>
          <given value="Jane"/>
        </name>
        <gender value="female"/>
        <birthDate value="1975-12-05"/>
        <address>
          <line value="100 Oak Court"/>
          <city value="Madison"/>
          <state value="WI"/>
          <postalCode value="53510"/>
          <country value="US"/>
        </address>
      </Patient>
    </resource>
  </entry>
  <entry>
    <fullUrl value="urn:uuid:61ebe359-bfdc-4613-8bf2-c5e300945f0d"/>
    <resource>
      <Organization>
        <id value="rtpbc-organization-03m"/>
        <meta>
          <profile
                   value="http://hl7.org/fhir/us/carin-rtpbc/StructureDefinition/rtpbc-pharmacy-organization"/>
        </meta>
        <text>
          <status value="generated"/>
          <div xmlns="http://www.w3.org/1999/xhtml"><p><b>Generated Narrative</b></p><p><b>id</b>: rtpbc-organization-03m</p><p><b>meta</b>: </p><p><b>identifier</b>: id: 5515515515</p><p><b>active</b>: true</p><p><b>type</b>: <span title="Codes: {http://ncpdp.org/pharmacy-type M}">Mail Order</span></p><p><b>name</b>: My Mail Service Pharmacy</p><p><b>telecom</b>: ph: 5551234567</p><p><b>address</b>: 10001 Oakland Road Milwaukee WI 54444 US </p></div>
        </text>
        <identifier>
          <system value="http://hl7.org/fhir/sid/us-npi"/>
          <value value="5515515515"/>
        </identifier>
        <active value="true"/>
        <type>
          <coding>
            <system value="http://ncpdp.org/pharmacy-type"/>
            <code value="M"/>
            <display value="Mail Order"/>
          </coding>
        </type>
        <name value="My Mail Service Pharmacy"/>
        <telecom>
          <system value="phone"/>
          <value value="5551234567"/>
        </telecom>
        <address>
          <line value="10001 Oakland Road"/>
          <city value="Milwaukee"/>
          <state value="WI"/>
          <postalCode value="54444"/>
          <country value="US"/>
        </address>
      </Organization>
    </resource>
  </entry>
</Bundle>