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
<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>