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

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XML Format: ClaimResponse-rtpbc-claim-response-03

Raw xml

<ClaimResponse xmlns="http://hl7.org/fhir">
  <id value="rtpbc-claim-response-03"/>
  <meta>
    <profile
             value="http://hl7.org/fhir/us/carin/StructureDefinition/rtpbc-response"/>
  </meta>
  <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>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>
  </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://terminology.hl7.org/CodeSystem/ndc-11"/>
        <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>