This page is part of the Consumer Real-time Pharmacy Benefit Check (v0.1.0: STU 1 Ballot 1) based on FHIR R4. The current version which supercedes this version is 1.0.0. For a full list of available versions, see the Directory of published versions 
JSON Format: Bundle-rtpbc-bundle-response-03-w-header
Raw json
{
"resourceType" : "Bundle",
"id" : "rtpbc-bundle-response-03-w-header",
"meta" : {
"profile" : [
"http://hl7.org/fhir/us/carin/StructureDefinition/rtpbc-response-bundle"
]
},
"type" : "message",
"timestamp" : "2019-11-15T13:10:15-05:00",
"entry" : [
{
"fullUrl" : "urn:uuid:61ebe359-bfdc-4613-8bf2-c5e300945f0a",
"resource" : {
"resourceType" : "MessageHeader",
"id" : "rtpbc-messageheader-response-03",
"meta" : {
"profile" : [
"http://hl7.org/fhir/us/carin/StructureDefinition/rtpbc-response-messageheader"
]
},
"text" : {
"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p><b>Generated Narrative with Details</b></p><p><b>id</b>: rtpbc-messageheader-response-03</p><p><b>meta</b>: </p><p><b>event</b>: RTPBC Response (Details: http://hl7.org/fhir/us/carin/CodeSystem/rtpbc-event-type code rtpbc-response = 'RTPBC Response', stated as 'RTPBC Response')</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.html\">Generated Summary: id: rtpbc-claim-response-03; rtpbc-03-response; status: active; <span title=\"Codes: {http://terminology.hl7.org/CodeSystem/claim-type pharmacy}\">Pharmacy</span>; use: predetermination; created: Nov 1, 2019 4:20:59 PM; outcome: complete; disposition: Processed successfully</a></p></div>"
},
"eventCoding" : {
"system" : "http://hl7.org/fhir/us/carin/CodeSystem/rtpbc-event-type",
"code" : "rtpbc-response",
"display" : "RTPBC Response"
},
"source" : {
"name" : "PharmacyBenefitsCompany",
"endpoint" : "http://example.org/PharmacyBenefitsCo/fhir"
},
"response" : {
"identifier" : "rtpbc-messageheader-request-03",
"code" : "ok"
},
"focus" : [
{
"reference" : "ClaimResponse/rtpbc-claim-response-03"
}
]
}
},
{
"fullUrl" : "urn:uuid:61ebe359-bfdc-4613-8bf2-c5e300945f0b",
"resource" : {
"resourceType" : "ClaimResponse",
"id" : "rtpbc-claim-response-03",
"meta" : {
"profile" : [
"http://hl7.org/fhir/us/carin/StructureDefinition/rtpbc-response"
]
},
"text" : {
"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p><b>Generated Narrative with Details</b></p><p><b>id</b>: rtpbc-claim-response-03</p><p><b>meta</b>: </p><p><b>identifier</b>: rtpbc-03-response</p><p><b>status</b>: active</p><p><b>type</b>: Pharmacy <span style=\"background: LightGoldenRodYellow\">(Details : {http://terminology.hl7.org/CodeSystem/claim-type code 'pharmacy' = 'Pharmacy', given as '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; 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>: </p><p><b>request</b>: </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><p><b>noteNumber</b>: 1</p><blockquote><p><b>adjudication</b></p><p><b>category</b>: Copay <span style=\"background: LightGoldenRodYellow\">(Details : {http://hl7.org/fhir/us/carin/CodeSystem/rtpbc-patient-pay-type code 'copay' = 'Copay', given as 'Copay'})</span></p><p><b>amount</b>: </p></blockquote><blockquote><p><b>adjudication</b></p><p><b>category</b>: Per prescription coinsurance <span style=\"background: LightGoldenRodYellow\">(Details : {http://hl7.org/fhir/us/carin/CodeSystem/rtpbc-patient-pay-type code 'coinsurance' = 'Per prescription coinsurance', given as 'Per prescription coinsurance'})</span></p><p><b>amount</b>: </p></blockquote><blockquote><p><b>adjudication</b></p><p><b>category</b>: Total patient responsibility <span style=\"background: LightGoldenRodYellow\">(Details : {http://hl7.org/fhir/us/carin/CodeSystem/rtpbc-patient-pay-type code 'total' = 'Total patient responsibility', given as '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.html\">Generated Summary: id: rtpbc-organization-03m; 0999029; <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>: Prozac 10mg capsule <span style=\"background: LightGoldenRodYellow\">(Details : {http://terminology.hl7.org/CodeSystem/ndc-11 code '00777310402' = 'Prozac 10mg capsule', given as 'Prozac 10mg capsule'})</span></p><p><b>quantity</b>: 180 EA</p><p><b>noteNumber</b>: 2</p><h3>Adjudications</h3><table class=\"grid\"><tr><td>-</td></tr><tr><td>*</td></tr><tr><td>*</td></tr><tr><td>*</td></tr></table></blockquote><blockquote><p><b>processNote</b></p><p><b>number</b>: 1</p><p><b>text</b>: Covered</p></blockquote><blockquote><p><b>processNote</b></p><p><b>number</b>: 2</p><p><b>text</b>: Covered</p></blockquote></div>"
},
"identifier" : [
{
"value" : "rtpbc-03-response"
}
],
"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" : [
{
"itemSequence" : 1,
"noteNumber" : [
1
],
"adjudication" : [
{
"category" : {
"coding" : [
{
"system" : "http://hl7.org/fhir/us/carin/CodeSystem/rtpbc-patient-pay-type",
"code" : "copay",
"display" : "Copay"
}
]
},
"amount" : {
"value" : 10,
"currency" : "USD"
}
},
{
"category" : {
"coding" : [
{
"system" : "http://hl7.org/fhir/us/carin/CodeSystem/rtpbc-patient-pay-type",
"code" : "coinsurance",
"display" : "Per prescription coinsurance"
}
]
},
"amount" : {
"value" : 15,
"currency" : "USD"
}
},
{
"category" : {
"coding" : [
{
"system" : "http://hl7.org/fhir/us/carin/CodeSystem/rtpbc-patient-pay-type",
"code" : "total",
"display" : "Total patient responsibility"
}
]
},
"amount" : {
"value" : 25,
"currency" : "USD"
}
}
]
}
],
"addItem" : [
{
"extension" : [
{
"url" : "http://hl7.org/fhir/us/carin/StructureDefinition/rtpbc-isAlternative",
"valueBoolean" : true
}
],
"itemSequence" : [
1
],
"provider" : [
{
"reference" : "Organization/rtpbc-organization-03m"
}
],
"productOrService" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/ndc-11",
"code" : "00777310402",
"display" : "Prozac 10mg capsule"
}
]
},
"quantity" : {
"value" : 180,
"unit" : "EA"
},
"noteNumber" : [
2
],
"adjudication" : [
{
"category" : {
"coding" : [
{
"system" : "http://hl7.org/fhir/us/carin/CodeSystem/rtpbc-patient-pay-type",
"code" : "copay",
"display" : "Copay"
}
]
},
"amount" : {
"value" : 20,
"currency" : "USD"
}
},
{
"category" : {
"coding" : [
{
"system" : "http://hl7.org/fhir/us/carin/CodeSystem/rtpbc-patient-pay-type",
"code" : "coinsurance",
"display" : "Per prescription coinsurance"
}
]
},
"amount" : {
"value" : 30,
"currency" : "USD"
}
},
{
"category" : {
"coding" : [
{
"system" : "http://hl7.org/fhir/us/carin/CodeSystem/rtpbc-patient-pay-type",
"code" : "total",
"display" : "Total patient responsibility"
}
]
},
"amount" : {
"value" : 50,
"currency" : "USD"
}
}
]
}
],
"processNote" : [
{
"number" : 1,
"text" : "Covered"
},
{
"number" : 2,
"text" : "Covered"
}
]
}
},
{
"fullUrl" : "urn:uuid:61ebe359-bfdc-4613-8bf2-c5e300945f0c",
"resource" : {
"resourceType" : "Patient",
"id" : "rtpbc-patient-03",
"meta" : {
"profile" : [
"http://hl7.org/fhir/us/carin/StructureDefinition/rtpbc-patient"
]
},
"text" : {
"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p><b>Generated Narrative with Details</b></p><p><b>id</b>: rtpbc-patient-03</p><p><b>meta</b>: </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>"
},
"name" : [
{
"family" : "Doe",
"given" : [
"Jane"
]
}
],
"gender" : "female",
"birthDate" : "1975-12-05",
"address" : [
{
"line" : [
"100 Oak Court"
],
"city" : "Madison",
"state" : "WI",
"postalCode" : "53510",
"country" : "US"
}
]
}
},
{
"fullUrl" : "urn:uuid:61ebe359-bfdc-4613-8bf2-c5e300945f0d",
"resource" : {
"resourceType" : "Organization",
"id" : "rtpbc-organization-03m",
"meta" : {
"profile" : [
"http://hl7.org/fhir/us/carin/StructureDefinition/rtpbc-pharmacy"
]
},
"text" : {
"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p><b>Generated Narrative with Details</b></p><p><b>id</b>: rtpbc-organization-03m</p><p><b>meta</b>: </p><p><b>identifier</b>: 5515515515</p><p><b>type</b>: Mail Order <span style=\"background: LightGoldenRodYellow\">(Details : {http://ncpdp.org/pharmacy-type code 'M' = 'M', given as '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>"
},
"identifier" : [
{
"system" : "http://hl7.org/fhir/sid/us-npi",
"value" : "5515515515"
}
],
"type" : [
{
"coding" : [
{
"system" : "http://ncpdp.org/pharmacy-type",
"code" : "M",
"display" : "Mail Order"
}
]
}
],
"name" : "My Mail Service Pharmacy",
"telecom" : [
{
"system" : "phone",
"value" : "5551234567"
}
],
"address" : [
{
"line" : [
"10001 Oakland Road"
],
"city" : "Milwaukee",
"state" : "WI",
"postalCode" : "54444",
"country" : "US"
}
]
}
}
]
}
