CARIN Consumer Realtime Pharmacy Benefit Check
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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

XML Format: Bundle-rtpbc-bundle-response-03

Raw xml 


<Bundle xmlns="http://hl7.org/fhir">
  <id value="rtpbc-bundle-response-03"/>
  <meta>
    <versionId value="8"/>
    <lastUpdated value="2019-11-14T17:29:04.000-05:00"/>
  </meta>
  <type value="collection"/>
  <entry>
    <fullUrl value="http://example.org/ClaimResponse/rtpbc-claim-response-03"/>
    <resource>
      <ClaimResponse>
        <id value="rtpbc-claim-response-03"/>
        <text>
          <status value="generated"/>
          <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>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://example.org/ndc11/placeholder code '00777310402' = '00777310402', 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>
        </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>
          <itemSequence value="1"/>
          <noteNumber value="1"/>
          <adjudication>
            <category>
              <coding>
                <system
                        value="http://hl7.org/fhir/us/carin/CodeSystem/rtpbc-patient-pay-type"/>
                <code value="copay"/>
                <display value="Copay"/>
              </coding>
            </category>
            <amount>
              <value value="10"/>
              <currency value="USD"/>
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system
                        value="http://hl7.org/fhir/us/carin/CodeSystem/rtpbc-patient-pay-type"/>
                <code value="coinsurance"/>
                <display value="Per prescription coinsurance"/>
              </coding>
            </category>
            <amount>
              <value value="15"/>
              <currency value="USD"/>
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system
                        value="http://hl7.org/fhir/us/carin/CodeSystem/rtpbc-patient-pay-type"/>
                <code value="total"/>
                <display value="Total patient responsibility"/>
              </coding>
            </category>
            <amount>
              <value value="25"/>
              <currency value="USD"/>
            </amount>
          </adjudication>
        </item>
        <addItem>
          <extension
                     url="http://hl7.org/fhir/us/carin/StructureDefinition/rtpbc-isAlternative">
            <valueBoolean value="true"/>
          </extension>
          <itemSequence value="1"/>
          <provider>
            <reference value="Organization/rtpbc-organization-03m"/>
          </provider>
          <productOrService>
            <coding>
              <system value="http://example.org/ndc11/placeholder"/>
              <code value="00777310402"/>
              <display value="Prozac 10mg capsule"/>
            </coding>
          </productOrService>
          <quantity>
            <value value="180"/>
            <unit value="EA"/>
          </quantity>
          <noteNumber value="2"/>
          <adjudication>
            <category>
              <coding>
                <system
                        value="http://hl7.org/fhir/us/carin/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/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/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>
        <processNote>
          <number value="1"/>
          <text value="Covered"/>
        </processNote>
        <processNote>
          <number value="2"/>
          <text value="Covered"/>
        </processNote>
      </ClaimResponse>
    </resource>
  </entry>
  <entry>
    <fullUrl value="http://example.org/Patient/rtpbc-patient-03"/>
    <resource>
      <Patient>
        <id value="rtpbc-patient-03"/>
        <text>
          <status value="generated"/>
          <div xmlns="http://www.w3.org/1999/xhtml">
                        <div class="hapiHeaderText">Jane 
                            <b>DOE </b>
                        </div>
                        <table class="hapiPropertyTable">
                            <tbody>
                                <tr>
                                    <td>Address</td>
                                    <td>
                                        <span>100 Oak Court </span>
                                        <br/>
                                        <span>Madison </span>
                                        <span>WI </span>
                                        <span>US </span>
                                    </td>
                                </tr>
                                <tr>
                                    <td>Date of birth</td>
                                    <td>
                                        <span>05 December 1975</span>
                                    </td>
                                </tr>
                            </tbody>
                        </table>
                    </div>
        </text>
        <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="http://example.org/Organization/rtpbc-organization-03m"/>
    <resource>
      <Organization>
        <id value="rtpbc-organization-03m"/>
        <text>
          <status value="generated"/>
          <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>identifier</b>: 5515515515</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>
        <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>