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

: Example RTPBC Response - not covered - TTL Representation

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@prefix fhir: <http://hl7.org/fhir/> .
@prefix owl: <http://www.w3.org/2002/07/owl#> .
@prefix rdfs: <http://www.w3.org/2000/01/rdf-schema#> .
@prefix xsd: <http://www.w3.org/2001/XMLSchema#> .

# - resource -------------------------------------------------------------------

 a fhir:ClaimResponse;
  fhir:nodeRole fhir:treeRoot;
  fhir:Resource.id [ fhir:value "rtpbc-claim-response-not-covered"];
  fhir:Resource.meta [
     fhir:Meta.profile [
       fhir:value "http://hl7.org/fhir/us/carin-rtpbc/StructureDefinition/rtpbc-response-claimresponse";
       fhir:index 0;
       fhir:link <http://hl7.org/fhir/us/carin-rtpbc/StructureDefinition/rtpbc-response-claimresponse>     ]
  ];
  fhir:DomainResource.text [
     fhir:Narrative.status [ fhir:value "generated" ];
     fhir:Narrative.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>"
  ];
  fhir:ClaimResponse.identifier [
     fhir:index 0;
     fhir:Identifier.value [ fhir:value "rtpbc-03-response-c-r" ]
  ];
  fhir:ClaimResponse.status [ fhir:value "active"];
  fhir:ClaimResponse.type [
     fhir:CodeableConcept.coding [
       fhir:index 0;
       fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/claim-type" ];
       fhir:Coding.code [ fhir:value "pharmacy" ];
       fhir:Coding.display [ fhir:value "Pharmacy" ]     ]
  ];
  fhir:ClaimResponse.use [ fhir:value "predetermination"];
  fhir:ClaimResponse.patient [
     fhir:Reference.reference [ fhir:value "Patient/rtpbc-patient-03" ]
  ];
  fhir:ClaimResponse.created [ fhir:value "2019-11-01T11:20:59-05:00"^^xsd:dateTime];
  fhir:ClaimResponse.insurer [
     fhir:Reference.identifier [
       fhir:Identifier.value [ fhir:value "Pharmacy Plans US" ]     ]
  ];
  fhir:ClaimResponse.request [
     fhir:Reference.identifier [
       fhir:Identifier.value [ fhir:value "rtpbc-03" ]     ]
  ];
  fhir:ClaimResponse.outcome [ fhir:value "complete"];
  fhir:ClaimResponse.disposition [ fhir:value "Processed successfully"];
  fhir:ClaimResponse.item [
     fhir:index 0;
     fhir:Element.extension [
       fhir:index 0;
       fhir:Extension.url [ fhir:value "http://hl7.org/fhir/us/carin-rtpbc/StructureDefinition/rtpbc-benefitRestriction" ];
       fhir:Extension.valueCoding [
         fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/carin-rtpbc/CodeSystem/rtpbc-benefit-restriction" ];
         fhir:Coding.code [ fhir:value "not-covered" ];
         fhir:Coding.display [ fhir:value "Not covered" ]       ]     ];
     fhir:ClaimResponse.item.itemSequence [ fhir:value "1"^^xsd:positiveInteger ];
     fhir:ClaimResponse.item.adjudication [
       fhir:index 0;
       fhir:ClaimResponse.item.adjudication.category [
         fhir:CodeableConcept.coding [
           fhir:index 0;
           fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/carin-rtpbc/CodeSystem/rtpbc-patient-pay-type" ];
           fhir:Coding.code [ fhir:value "eligible" ];
           fhir:Coding.display [ fhir:value "Eligible amount" ]         ]       ];
       fhir:ClaimResponse.item.adjudication.amount [
         fhir:Money.value [ fhir:value "0"^^xsd:decimal ];
         fhir:Money.currency [ fhir:value "USD" ]       ]     ]
  ];
  fhir:ClaimResponse.addItem [
     fhir:index 0;
     fhir:Element.extension [
       fhir:index 0;
       fhir:Extension.url [ fhir:value "http://hl7.org/fhir/us/carin-rtpbc/StructureDefinition/rtpbc-isAlternative" ];
       fhir:Extension.valueBoolean [ fhir:value "true"^^xsd:boolean ]     ], [
       fhir:index 1;
       fhir:Extension.url [ fhir:value "http://hl7.org/fhir/us/carin-rtpbc/StructureDefinition/rtpbc-benefitRestriction" ];
       fhir:Extension.valueCoding [
         fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/carin-rtpbc/CodeSystem/rtpbc-benefit-restriction" ];
         fhir:Coding.code [ fhir:value "prior-auth" ];
         fhir:Coding.display [ fhir:value "Prior authorization required" ]       ]     ], [
       fhir:index 2;
       fhir:Extension.url [ fhir:value "http://hl7.org/fhir/us/carin-rtpbc/StructureDefinition/rtpbc-benefitRestriction" ];
       fhir:Extension.valueCoding [
         fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/carin-rtpbc/CodeSystem/rtpbc-benefit-restriction" ];
         fhir:Coding.code [ fhir:value "quantity-limit" ];
         fhir:Coding.display [ fhir:value "Quantity limit applies" ]       ]     ];
     fhir:ClaimResponse.addItem.itemSequence [
       fhir:value "1"^^xsd:positiveInteger;
       fhir:index 0     ];
     fhir:ClaimResponse.addItem.provider [
       fhir:index 0;
       fhir:Reference.reference [ fhir:value "Organization/rtpbc-organization-03m" ]     ];
     fhir:ClaimResponse.addItem.productOrService [
       fhir:CodeableConcept.coding [
         fhir:index 0;
         fhir:Coding.system [ fhir:value "http://www.nlm.nih.gov/research/umls/rxnorm" ];
         fhir:Coding.code [ fhir:value "1734642" ];
         fhir:Coding.display [ fhir:value "Zepatier 50 MG / 100 MG Oral Tablet" ]       ]     ];
     fhir:ClaimResponse.addItem.quantity [
       fhir:Quantity.value [ fhir:value "28"^^xsd:decimal ];
       fhir:Quantity.unit [ fhir:value "{Each}" ]     ];
     fhir:ClaimResponse.addItem.noteNumber [
       fhir:value "1"^^xsd:positiveInteger;
       fhir:index 0     ];
     fhir:ClaimResponse.addItem.adjudication [
       fhir:index 0;
       fhir:ClaimResponse.item.adjudication.category [
         fhir:CodeableConcept.coding [
           fhir:index 0;
           fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/carin-rtpbc/CodeSystem/rtpbc-patient-pay-type" ];
           fhir:Coding.code [ fhir:value "copay" ];
           fhir:Coding.display [ fhir:value "Copay" ]         ]       ];
       fhir:ClaimResponse.item.adjudication.amount [
         fhir:Money.value [ fhir:value "405"^^xsd:decimal ];
         fhir:Money.currency [ fhir:value "USD" ]       ]     ], [
       fhir:index 1;
       fhir:ClaimResponse.item.adjudication.category [
         fhir:CodeableConcept.coding [
           fhir:index 0;
           fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/carin-rtpbc/CodeSystem/rtpbc-patient-pay-type" ];
           fhir:Coding.code [ fhir:value "coinsurance" ];
           fhir:Coding.display [ fhir:value "Per prescription coinsurance" ]         ]       ];
       fhir:ClaimResponse.item.adjudication.amount [
         fhir:Money.value [ fhir:value "469"^^xsd:decimal ];
         fhir:Money.currency [ fhir:value "USD" ]       ]     ], [
       fhir:index 2;
       fhir:ClaimResponse.item.adjudication.category [
         fhir:CodeableConcept.coding [
           fhir:index 0;
           fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/carin-rtpbc/CodeSystem/rtpbc-patient-pay-type" ];
           fhir:Coding.code [ fhir:value "total" ];
           fhir:Coding.display [ fhir:value "Total patient responsibility" ]         ]       ];
       fhir:ClaimResponse.item.adjudication.amount [
         fhir:Money.value [ fhir:value "874"^^xsd:decimal ];
         fhir:Money.currency [ fhir:value "USD" ]       ]     ]
  ];
  fhir:ClaimResponse.processNote [
     fhir:index 0;
     fhir:ClaimResponse.processNote.number [ fhir:value "1"^^xsd:positiveInteger ];
     fhir:ClaimResponse.processNote.text [ fhir:value "Quantity limit: 28 tablets per month" ]
  ].

# - ontology header ------------------------------------------------------------

 a owl:Ontology;
  owl:imports fhir:fhir.ttl.