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: ClaimResponse-rtpbc-claim-response-03
Raw json
{
"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"
}
]
}
