Consumer Real-Time Pharmacy Benefit Check
1.0.0 - STU1
Consumer Real-Time Pharmacy Benefit Check
1.0.0 - STU1
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 
{
"resourceType" : "ClaimResponse",
"id" : "rtpbc-claim-response-not-covered",
"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-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>"
},
"identifier" : [
{
"value" : "rtpbc-03-response-c-r"
}
],
"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" : "not-covered",
"display" : "Not covered"
}
}
],
"itemSequence" : 1,
"adjudication" : [
{
"category" : {
"coding" : [
{
"system" : "http://hl7.org/fhir/us/carin-rtpbc/CodeSystem/rtpbc-patient-pay-type",
"code" : "eligible",
"display" : "Eligible amount"
}
]
},
"amount" : {
"value" : 0,
"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" : "prior-auth",
"display" : "Prior authorization required"
}
},
{
"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" : "quantity-limit",
"display" : "Quantity limit applies"
}
}
],
"itemSequence" : [
1
],
"provider" : [
{
"reference" : "Organization/rtpbc-organization-03m"
}
],
"productOrService" : {
"coding" : [
{
"system" : "http://www.nlm.nih.gov/research/umls/rxnorm",
"code" : "1734642",
"display" : "Zepatier 50 MG / 100 MG Oral Tablet"
}
]
},
"quantity" : {
"value" : 28,
"unit" : "{Each}"
},
"noteNumber" : [
1
],
"adjudication" : [
{
"category" : {
"coding" : [
{
"system" : "http://hl7.org/fhir/us/carin-rtpbc/CodeSystem/rtpbc-patient-pay-type",
"code" : "copay",
"display" : "Copay"
}
]
},
"amount" : {
"value" : 405,
"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" : 469,
"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" : 874,
"currency" : "USD"
}
}
]
}
],
"processNote" : [
{
"number" : 1,
"text" : "Quantity limit: 28 tablets per month"
}
]
}
IG © 2020+ HL7 International - Pharmacy. Package hl7.fhir.us.carin-rtpbc#1.0.0 based on FHIR 4.0.1. Generated 2020-08-25
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