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

SD.6 StructureDefinition-carin-rtpbc-request-claim

This profile constrains the Claim resource so that it can serve as the request in the consumer Real-time Pharmacy Benefit Check (RTPBC) process.

Data population is similar to a typical Claim predetermination request (where Claim.use set to “predetermination”), with the following key differences: Certain elements are fixed to values reflecting a medication-related request…

  • Claim.type = “pharmacy”
  • Claim.provider references an Organization resource that represents the patient’s preferred pharmacy
  • Claim.prescription is mandatory (referencing a MedicationRequest resource)
  • Claim.careTeam.provider is mandatory, referencing a Practitioner resource that identifies the prescriber
  • Claim.item elements are constrained to product identifiers and quantity units of measure describing medications

In addition, no pricing / cost information is submitted in the request since the goal of the exchange is learn the expected cost to the patient rather than reimbursement information for a pharmacy.

In this profile, the Claim references the following supported resources, each of which are profiled in this guide.

  • Patient (containing a small amount of identifying information to enable the insurer to locate the patient’s records)
  • Coverage (containing identification of the patient’s pharmacy benefit coverage)
  • MedicationRequest (containing excerpts from the prescription to be priced)
  • Practitioner (identifying the prescriber)
  • Organization (identifying the pharmacy)

Must Support elements in this profile

Client systems

  • All elements with a minimum cardinality of 1 that are also marked Must Support are essential for the responder to identify the applicable plan rules and accurately determine patient costs and coverage. The submitter MUST ensure that content in these elements is accurate and complete in order to receive reliable information in the response.

Responding systems

  • MUST make use of all pertinent information provided in the Claim request when determining cost and coverage

SD.6.1 Formal Views of Profile Content

Description of Profiles, Differentials, and Snapshots.

The official URL for this profile is: http://hl7.org/fhir/us/carin/StructureDefinition/rtpbc-request

Published on Sun Dec 08 05:00:00 UTC 2019 as a active by CARIN Alliance.

This profile builds on Claim

NameFlagsCard.TypeDescription & Constraintsdoco
.. Claim 0..*Claim
... id S1..1stringUnique Claim Resource Identifier
... identifier S1..1IdentifierRTPBC request identifier
.... value S1..1stringUnique RTPBC request ID
... status S1..1codeRequest status
Fixed Value: active
... type S1..1CodeableConceptRequested Service Type
Fixed Value: As shown
.... coding1..1CodingCode defined by a terminology system
Fixed Value: (complex)
..... system1..1uriIdentity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/claim-type
..... code1..1codeSymbol in syntax defined by the system
Fixed Value: pharmacy
..... display1..1stringRepresentation defined by the system
Fixed Value: Pharmacy
.... coding S1..1Coding
..... system S1..1uri
..... code S1..1code
... use S1..1codeProcessing Mode
Fixed Value: predetermination
... patient S1..1Reference(CARIN RTPBC Patient)Request Patient Information
.... reference S1..1stringPatient Reference
... created S1..1dateTimeCreated DateTime
... provider S1..1Reference(CARIN RTPBC PharmacyOrganization)Preferred Pharmacy
.... reference S1..1stringReference to Pharmacy Organization
... priority S1..1CodeableConceptProcessing priority
Fixed Value: As shown
.... coding1..1CodingCode defined by a terminology system
Fixed Value: (complex)
..... system1..1uriIdentity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/processpriority
..... code1..1codeSymbol in syntax defined by the system
Fixed Value: normal
..... display1..1stringRepresentation defined by the system
Fixed Value: Normal
.... coding S1..1Coding
..... system S1..1uri
..... code S1..1code
... prescription 1..1Reference(CARIN RTPBC Medication Request)Prescription Reference
.... reference 1..1string
... careTeam S1..1BackboneElementCare Team
.... sequence S1..1positiveIntFixed Value: 1
.... provider S1..1Reference(CARIN RTPBC Practitioner)Prescriber
..... reference S1..1stringPrescriber Reference
... insurance S1..1BackboneElementPharmacy Coverage
.... sequence S1..1positiveIntFixed Value: 1
.... focal S1..1booleanFixed Value: true
.... coverage S1..1Reference(CARIN RTPBC Coverage)Pharmacy Coverage Reference
..... reference S1..1stringPharmacy Coverage Reference
... item S1..1BackboneElementMax 1 item per request
.... sequence S1..1positiveIntFixed Value: 1
.... careTeamSequence S1..1positiveIntCare Team Sequence ID Reference
.... productOrService S1..1CodeableConceptPrescribed Product
Binding: CARIN RTPBC Prescribable Product Code Value Set (extensible)
..... coding S1..*Coding
...... system S1..1uri
...... code S1..1code
...... display S1..1stringProduct Description
.... quantity S1..1SimpleQuantityPrescribed Quantity
..... value S1..1decimalQuantity in Billing Units
..... unit S1..1stringBilling unit of measure
Binding: CARIN RTPBC Billing Unit Value Set (extensible)

doco Documentation for this format
NameFlagsCard.TypeDescription & Constraintsdoco
.. Claim I0..*ClaimClaim, Pre-determination or Pre-authorization
... id SΣ1..1stringUnique Claim Resource Identifier
... meta ΣI0..1MetaMetadata about the resource
... implicitRules ?!ΣI0..1uriA set of rules under which this content was created
... language I0..1codeLanguage of the resource content
Binding: CommonLanguages (preferred)
Max Binding: AllLanguages
... text I0..1NarrativeText summary of the resource, for human interpretation
... contained 0..*ResourceContained, inline Resources
... extension I0..*ExtensionAdditional content defined by implementations
... modifierExtension ?!I0..*ExtensionExtensions that cannot be ignored
... identifier SI1..1IdentifierRTPBC request identifier
.... id 0..1stringUnique id for inter-element referencing
.... extension I0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
.... use ?!ΣI0..1codeusual | official | temp | secondary | old (If known)
Binding: IdentifierUse (required)
.... type ΣI0..1CodeableConceptDescription of identifier
Binding: Identifier Type Codes (extensible)
.... system ΣI0..1uriThe namespace for the identifier value
Example General: http://www.acme.com/identifiers/patient
.... value SΣI1..1stringUnique RTPBC request ID
Example General: 123456
.... period ΣI0..1PeriodTime period when id is/was valid for use
.... assigner ΣI0..1Reference(Organization)Organization that issued id (may be just text)
... status ?!SΣI1..1codeRequest status
Binding: FinancialResourceStatusCodes (required)
Fixed Value: active
... type SΣI1..1CodeableConceptRequested Service Type
Binding: ClaimTypeCodes (extensible)
Fixed Value: As shown
.... id0..0stringUnique id for inter-element referencing
.... extension0..0ExtensionAdditional content defined by implementations
.... coding1..1CodingCode defined by a terminology system
Fixed Value: (complex)
..... id0..0stringUnique id for inter-element referencing
..... extension0..0ExtensionAdditional content defined by implementations
..... system1..1uriIdentity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/claim-type
..... version0..0stringVersion of the system - if relevant
..... code1..1codeSymbol in syntax defined by the system
Fixed Value: pharmacy
..... display1..1stringRepresentation defined by the system
Fixed Value: Pharmacy
..... userSelected0..0booleanIf this coding was chosen directly by the user
.... text0..0stringPlain text representation of the concept
.... id 0..1stringUnique id for inter-element referencing
.... extension I0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
.... coding SΣI1..1CodingCode defined by a terminology system
..... id 0..1stringUnique id for inter-element referencing
..... extension I0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
..... system SΣI1..1uriIdentity of the terminology system
..... version ΣI0..1stringVersion of the system - if relevant
..... code SΣI1..1codeSymbol in syntax defined by the system
..... display ΣI0..1stringRepresentation defined by the system
..... userSelected ΣI0..1booleanIf this coding was chosen directly by the user
.... text ΣI0..1stringPlain text representation of the concept
... subType I0..1CodeableConceptMore granular claim type
Binding: ExampleClaimSubTypeCodes (example)
... use SΣI1..1codeProcessing Mode
Binding: Use (required)
Fixed Value: predetermination
... patient SΣI1..1Reference(CARIN RTPBC Patient)Request Patient Information
.... id 0..1stringUnique id for inter-element referencing
.... extension I0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
.... reference SΣI1..1stringPatient Reference
.... type ΣI0..1uriType the reference refers to (e.g. "Patient")
Binding: ResourceType (extensible)
.... identifier ΣI0..1IdentifierLogical reference, when literal reference is not known
.... display ΣI0..1stringText alternative for the resource
... billablePeriod ΣI0..1PeriodRelevant time frame for the claim
... created SΣI1..1dateTimeCreated DateTime
... enterer I0..1Reference(Practitioner | PractitionerRole)Author of the claim
... insurer ΣI0..1Reference(Organization)Target
... provider SΣI1..1Reference(CARIN RTPBC PharmacyOrganization)Preferred Pharmacy
.... id 0..1stringUnique id for inter-element referencing
.... extension I0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
.... reference SΣI1..1stringReference to Pharmacy Organization
.... type ΣI0..1uriType the reference refers to (e.g. "Patient")
Binding: ResourceType (extensible)
.... identifier ΣI0..1IdentifierLogical reference, when literal reference is not known
.... display ΣI0..1stringText alternative for the resource
... priority SΣI1..1CodeableConceptProcessing priority
Binding: ProcessPriorityCodes (example)
Fixed Value: As shown
.... id0..0stringUnique id for inter-element referencing
.... extension0..0ExtensionAdditional content defined by implementations
.... coding1..1CodingCode defined by a terminology system
Fixed Value: (complex)
..... id0..0stringUnique id for inter-element referencing
..... extension0..0ExtensionAdditional content defined by implementations
..... system1..1uriIdentity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/processpriority
..... version0..0stringVersion of the system - if relevant
..... code1..1codeSymbol in syntax defined by the system
Fixed Value: normal
..... display1..1stringRepresentation defined by the system
Fixed Value: Normal
..... userSelected0..0booleanIf this coding was chosen directly by the user
.... text0..0stringPlain text representation of the concept
.... id 0..1stringUnique id for inter-element referencing
.... extension I0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
.... coding SΣI1..1CodingCode defined by a terminology system
..... id 0..1stringUnique id for inter-element referencing
..... extension I0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
..... system SΣI1..1uriIdentity of the terminology system
..... version ΣI0..1stringVersion of the system - if relevant
..... code SΣI1..1codeSymbol in syntax defined by the system
..... display ΣI0..1stringRepresentation defined by the system
..... userSelected ΣI0..1booleanIf this coding was chosen directly by the user
.... text ΣI0..1stringPlain text representation of the concept
... fundsReserve I0..1CodeableConceptFor whom to reserve funds
Binding: Funds Reservation Codes (example)
... related I0..*BackboneElementPrior or corollary claims
.... id 0..1stringUnique id for inter-element referencing
.... extension I0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!ΣI0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... claim I0..1Reference(Claim)Reference to the related claim
.... relationship I0..1CodeableConceptHow the reference claim is related
Binding: ExampleRelatedClaimRelationshipCodes (example)
.... reference I0..1IdentifierFile or case reference
... prescription I1..1Reference(CARIN RTPBC Medication Request)Prescription Reference
.... id 0..1stringUnique id for inter-element referencing
.... extension I0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
.... reference ΣI1..1stringLiteral reference, Relative, internal or absolute URL
.... type ΣI0..1uriType the reference refers to (e.g. "Patient")
Binding: ResourceType (extensible)
.... identifier ΣI0..1IdentifierLogical reference, when literal reference is not known
.... display ΣI0..1stringText alternative for the resource
... originalPrescription I0..1Reference(DeviceRequest | MedicationRequest | VisionPrescription)Original prescription if superseded by fulfiller
... payee I0..1BackboneElementRecipient of benefits payable
.... id 0..1stringUnique id for inter-element referencing
.... extension I0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!ΣI0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... type I1..1CodeableConceptCategory of recipient
Binding: Claim Payee Type Codes (example)
.... party I0..1Reference(Practitioner | PractitionerRole | Organization | Patient | RelatedPerson)Recipient reference
... referral I0..1Reference(ServiceRequest)Treatment referral
... facility I0..1Reference(Location)Servicing facility
... careTeam SI1..1BackboneElementCare Team
.... id 0..1stringUnique id for inter-element referencing
.... extension I0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!ΣI0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... sequence SI1..1positiveIntOrder of care team
Fixed Value: 1
.... provider SI1..1Reference(CARIN RTPBC Practitioner)Prescriber
..... id 0..1stringUnique id for inter-element referencing
..... extension I0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
..... reference SΣI1..1stringPrescriber Reference
..... type ΣI0..1uriType the reference refers to (e.g. "Patient")
Binding: ResourceType (extensible)
..... identifier ΣI0..1IdentifierLogical reference, when literal reference is not known
..... display ΣI0..1stringText alternative for the resource
.... responsible I0..1booleanIndicator of the lead practitioner
.... role I0..1CodeableConceptFunction within the team
Binding: ClaimCareTeamRoleCodes (example)
.... qualification I0..1CodeableConceptPractitioner credential or specialization
Binding: ExampleProviderQualificationCodes (example)
... supportingInfo I0..*BackboneElementSupporting information
.... id 0..1stringUnique id for inter-element referencing
.... extension I0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!ΣI0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... sequence I1..1positiveIntInformation instance identifier
.... category I1..1CodeableConceptClassification of the supplied information
Binding: ClaimInformationCategoryCodes (example)
.... code I0..1CodeableConceptType of information
Binding: ExceptionCodes (example)
.... timing[x] I0..1When it occurred
..... timingDatedate
..... timingPeriodPeriod
.... value[x] I0..1Data to be provided
..... valueBooleanboolean
..... valueStringstring
..... valueQuantityQuantity
..... valueAttachmentAttachment
..... valueReferenceReference(Resource)
.... reason I0..1CodeableConceptExplanation for the information
Binding: MissingToothReasonCodes (example)
... diagnosis I0..*BackboneElementPertinent diagnosis information
.... id 0..1stringUnique id for inter-element referencing
.... extension I0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!ΣI0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... sequence I1..1positiveIntDiagnosis instance identifier
.... diagnosis[x] I1..1Nature of illness or problem
Binding: ICD-10Codes (example)
..... diagnosisCodeableConceptCodeableConcept
..... diagnosisReferenceReference(Condition)
.... type I0..*CodeableConceptTiming or nature of the diagnosis
Binding: ExampleDiagnosisTypeCodes (example)
.... onAdmission I0..1CodeableConceptPresent on admission
Binding: ExampleDiagnosisOnAdmissionCodes (example)
.... packageCode I0..1CodeableConceptPackage billing code
Binding: ExampleDiagnosisRelatedGroupCodes (example)
... procedure I0..*BackboneElementClinical procedures performed
.... id 0..1stringUnique id for inter-element referencing
.... extension I0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!ΣI0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... sequence I1..1positiveIntProcedure instance identifier
.... type I0..*CodeableConceptCategory of Procedure
Binding: ExampleProcedureTypeCodes (example)
.... date I0..1dateTimeWhen the procedure was performed
.... procedure[x] I1..1Specific clinical procedure
Binding: ICD-10ProcedureCodes (example)
..... procedureCodeableConceptCodeableConcept
..... procedureReferenceReference(Procedure)
.... udi I0..*Reference(Device)Unique device identifier
... insurance SΣI1..1BackboneElementPharmacy Coverage
.... id 0..1stringUnique id for inter-element referencing
.... extension I0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!ΣI0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... sequence SΣI1..1positiveIntInsurance instance identifier
Fixed Value: 1
.... focal SΣI1..1booleanCoverage to be used for adjudication
Fixed Value: true
.... identifier I0..1IdentifierPre-assigned Claim number
.... coverage SΣI1..1Reference(CARIN RTPBC Coverage)Pharmacy Coverage Reference
..... id 0..1stringUnique id for inter-element referencing
..... extension I0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
..... reference SΣI1..1stringPharmacy Coverage Reference
..... type ΣI0..1uriType the reference refers to (e.g. "Patient")
Binding: ResourceType (extensible)
..... identifier ΣI0..1IdentifierLogical reference, when literal reference is not known
..... display ΣI0..1stringText alternative for the resource
.... businessArrangement I0..1stringAdditional provider contract number
.... preAuthRef I0..*stringPrior authorization reference number
.... claimResponse I0..1Reference(ClaimResponse)Adjudication results
... accident I0..1BackboneElementDetails of the event
.... id 0..1stringUnique id for inter-element referencing
.... extension I0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!ΣI0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... date I1..1dateWhen the incident occurred
.... type I0..1CodeableConceptThe nature of the accident
Binding: V3 Value SetActIncidentCode (extensible)
.... location[x] I0..1Where the event occurred
..... locationAddressAddress
..... locationReferenceReference(Location)
... item SI1..1BackboneElementMax 1 item per request
.... id 0..1stringUnique id for inter-element referencing
.... extension I0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!ΣI0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... sequence SI1..1positiveIntItem instance identifier
Fixed Value: 1
.... careTeamSequence SI1..1positiveIntCare Team Sequence ID Reference
.... diagnosisSequence I0..*positiveIntApplicable diagnoses
.... procedureSequence I0..*positiveIntApplicable procedures
.... informationSequence I0..*positiveIntApplicable exception and supporting information
.... revenue I0..1CodeableConceptRevenue or cost center code
Binding: ExampleRevenueCenterCodes (example)
.... category I0..1CodeableConceptBenefit classification
Binding: BenefitCategoryCodes (example)
.... productOrService SI1..1CodeableConceptPrescribed Product
Binding: CARIN RTPBC Prescribable Product Code Value Set (extensible)
..... id 0..1stringUnique id for inter-element referencing
..... extension I0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
..... coding SΣI1..*CodingCode defined by a terminology system
...... id 0..1stringUnique id for inter-element referencing
...... extension I0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
...... system SΣI1..1uriIdentity of the terminology system
...... version ΣI0..1stringVersion of the system - if relevant
...... code SΣI1..1codeSymbol in syntax defined by the system
...... display SΣI1..1stringProduct Description
...... userSelected ΣI0..1booleanIf this coding was chosen directly by the user
..... text ΣI0..1stringPlain text representation of the concept
.... modifier I0..*CodeableConceptProduct or service billing modifiers
Binding: ModifierTypeCodes (example)
.... programCode I0..*CodeableConceptProgram the product or service is provided under
Binding: ExampleProgramReasonCodes (example)
.... serviced[x] I0..1Date or dates of service or product delivery
..... servicedDatedate
..... servicedPeriodPeriod
.... location[x] I0..1Place of service or where product was supplied
Binding: ExampleServicePlaceCodes (example)
..... locationCodeableConceptCodeableConcept
..... locationAddressAddress
..... locationReferenceReference(Location)
.... quantity SI1..1SimpleQuantityPrescribed Quantity
..... id 0..1stringUnique id for inter-element referencing
..... extension I0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
..... value SΣI1..1decimalQuantity in Billing Units
..... unit SΣI1..1stringBilling unit of measure
Binding: CARIN RTPBC Billing Unit Value Set (extensible)
..... system ΣI0..1uriSystem that defines coded unit form
..... code ΣI0..1codeCoded form of the unit
.... unitPrice I0..1MoneyFee, charge or cost per item
.... factor I0..1decimalPrice scaling factor
.... net I0..1MoneyTotal item cost
.... udi I0..*Reference(Device)Unique device identifier
.... bodySite I0..1CodeableConceptAnatomical location
Binding: OralSiteCodes (example)
.... subSite I0..*CodeableConceptAnatomical sub-location
Binding: SurfaceCodes (example)
.... encounter I0..*Reference(Encounter)Encounters related to this billed item
.... detail I0..*BackboneElementProduct or service provided
..... id 0..1stringUnique id for inter-element referencing
..... extension I0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!ΣI0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... sequence I1..1positiveIntItem instance identifier
..... revenue I0..1CodeableConceptRevenue or cost center code
Binding: ExampleRevenueCenterCodes (example)
..... category I0..1CodeableConceptBenefit classification
Binding: BenefitCategoryCodes (example)
..... productOrService I1..1CodeableConceptBilling, service, product, or drug code
Binding: USCLSCodes (example)
..... modifier I0..*CodeableConceptService/Product billing modifiers
Binding: ModifierTypeCodes (example)
..... programCode I0..*CodeableConceptProgram the product or service is provided under
Binding: ExampleProgramReasonCodes (example)
..... quantity I0..1SimpleQuantityCount of products or services
..... unitPrice I0..1MoneyFee, charge or cost per item
..... factor I0..1decimalPrice scaling factor
..... net I0..1MoneyTotal item cost
..... udi I0..*Reference(Device)Unique device identifier
..... subDetail I0..*BackboneElementProduct or service provided
...... id 0..1stringUnique id for inter-element referencing
...... extension I0..*ExtensionAdditional content defined by implementations
...... modifierExtension ?!ΣI0..*ExtensionExtensions that cannot be ignored even if unrecognized
...... sequence I1..1positiveIntItem instance identifier
...... revenue I0..1CodeableConceptRevenue or cost center code
Binding: ExampleRevenueCenterCodes (example)
...... category I0..1CodeableConceptBenefit classification
Binding: BenefitCategoryCodes (example)
...... productOrService I1..1CodeableConceptBilling, service, product, or drug code
Binding: USCLSCodes (example)
...... modifier I0..*CodeableConceptService/Product billing modifiers
Binding: ModifierTypeCodes (example)
...... programCode I0..*CodeableConceptProgram the product or service is provided under
Binding: ExampleProgramReasonCodes (example)
...... quantity I0..1SimpleQuantityCount of products or services
...... unitPrice I0..1MoneyFee, charge or cost per item
...... factor I0..1decimalPrice scaling factor
...... net I0..1MoneyTotal item cost
...... udi I0..*Reference(Device)Unique device identifier
... total I0..1MoneyTotal claim cost

doco Documentation for this format

Differential View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Claim 0..*Claim
... id S1..1stringUnique Claim Resource Identifier
... identifier S1..1IdentifierRTPBC request identifier
.... value S1..1stringUnique RTPBC request ID
... status S1..1codeRequest status
Fixed Value: active
... type S1..1CodeableConceptRequested Service Type
Fixed Value: As shown
.... coding1..1CodingCode defined by a terminology system
Fixed Value: (complex)
..... system1..1uriIdentity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/claim-type
..... code1..1codeSymbol in syntax defined by the system
Fixed Value: pharmacy
..... display1..1stringRepresentation defined by the system
Fixed Value: Pharmacy
.... coding S1..1Coding
..... system S1..1uri
..... code S1..1code
... use S1..1codeProcessing Mode
Fixed Value: predetermination
... patient S1..1Reference(CARIN RTPBC Patient)Request Patient Information
.... reference S1..1stringPatient Reference
... created S1..1dateTimeCreated DateTime
... provider S1..1Reference(CARIN RTPBC PharmacyOrganization)Preferred Pharmacy
.... reference S1..1stringReference to Pharmacy Organization
... priority S1..1CodeableConceptProcessing priority
Fixed Value: As shown
.... coding1..1CodingCode defined by a terminology system
Fixed Value: (complex)
..... system1..1uriIdentity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/processpriority
..... code1..1codeSymbol in syntax defined by the system
Fixed Value: normal
..... display1..1stringRepresentation defined by the system
Fixed Value: Normal
.... coding S1..1Coding
..... system S1..1uri
..... code S1..1code
... prescription 1..1Reference(CARIN RTPBC Medication Request)Prescription Reference
.... reference 1..1string
... careTeam S1..1BackboneElementCare Team
.... sequence S1..1positiveIntFixed Value: 1
.... provider S1..1Reference(CARIN RTPBC Practitioner)Prescriber
..... reference S1..1stringPrescriber Reference
... insurance S1..1BackboneElementPharmacy Coverage
.... sequence S1..1positiveIntFixed Value: 1
.... focal S1..1booleanFixed Value: true
.... coverage S1..1Reference(CARIN RTPBC Coverage)Pharmacy Coverage Reference
..... reference S1..1stringPharmacy Coverage Reference
... item S1..1BackboneElementMax 1 item per request
.... sequence S1..1positiveIntFixed Value: 1
.... careTeamSequence S1..1positiveIntCare Team Sequence ID Reference
.... productOrService S1..1CodeableConceptPrescribed Product
Binding: CARIN RTPBC Prescribable Product Code Value Set (extensible)
..... coding S1..*Coding
...... system S1..1uri
...... code S1..1code
...... display S1..1stringProduct Description
.... quantity S1..1SimpleQuantityPrescribed Quantity
..... value S1..1decimalQuantity in Billing Units
..... unit S1..1stringBilling unit of measure
Binding: CARIN RTPBC Billing Unit Value Set (extensible)

doco Documentation for this format

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Claim I0..*ClaimClaim, Pre-determination or Pre-authorization
... id SΣ1..1stringUnique Claim Resource Identifier
... meta ΣI0..1MetaMetadata about the resource
... implicitRules ?!ΣI0..1uriA set of rules under which this content was created
... language I0..1codeLanguage of the resource content
Binding: CommonLanguages (preferred)
Max Binding: AllLanguages
... text I0..1NarrativeText summary of the resource, for human interpretation
... contained 0..*ResourceContained, inline Resources
... extension I0..*ExtensionAdditional content defined by implementations
... modifierExtension ?!I0..*ExtensionExtensions that cannot be ignored
... identifier SI1..1IdentifierRTPBC request identifier
.... id 0..1stringUnique id for inter-element referencing
.... extension I0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
.... use ?!ΣI0..1codeusual | official | temp | secondary | old (If known)
Binding: IdentifierUse (required)
.... type ΣI0..1CodeableConceptDescription of identifier
Binding: Identifier Type Codes (extensible)
.... system ΣI0..1uriThe namespace for the identifier value
Example General: http://www.acme.com/identifiers/patient
.... value SΣI1..1stringUnique RTPBC request ID
Example General: 123456
.... period ΣI0..1PeriodTime period when id is/was valid for use
.... assigner ΣI0..1Reference(Organization)Organization that issued id (may be just text)
... status ?!SΣI1..1codeRequest status
Binding: FinancialResourceStatusCodes (required)
Fixed Value: active
... type SΣI1..1CodeableConceptRequested Service Type
Binding: ClaimTypeCodes (extensible)
Fixed Value: As shown
.... id0..0stringUnique id for inter-element referencing
.... extension0..0ExtensionAdditional content defined by implementations
.... coding1..1CodingCode defined by a terminology system
Fixed Value: (complex)
..... id0..0stringUnique id for inter-element referencing
..... extension0..0ExtensionAdditional content defined by implementations
..... system1..1uriIdentity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/claim-type
..... version0..0stringVersion of the system - if relevant
..... code1..1codeSymbol in syntax defined by the system
Fixed Value: pharmacy
..... display1..1stringRepresentation defined by the system
Fixed Value: Pharmacy
..... userSelected0..0booleanIf this coding was chosen directly by the user
.... text0..0stringPlain text representation of the concept
.... id 0..1stringUnique id for inter-element referencing
.... extension I0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
.... coding SΣI1..1CodingCode defined by a terminology system
..... id 0..1stringUnique id for inter-element referencing
..... extension I0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
..... system SΣI1..1uriIdentity of the terminology system
..... version ΣI0..1stringVersion of the system - if relevant
..... code SΣI1..1codeSymbol in syntax defined by the system
..... display ΣI0..1stringRepresentation defined by the system
..... userSelected ΣI0..1booleanIf this coding was chosen directly by the user
.... text ΣI0..1stringPlain text representation of the concept
... subType I0..1CodeableConceptMore granular claim type
Binding: ExampleClaimSubTypeCodes (example)
... use SΣI1..1codeProcessing Mode
Binding: Use (required)
Fixed Value: predetermination
... patient SΣI1..1Reference(CARIN RTPBC Patient)Request Patient Information
.... id 0..1stringUnique id for inter-element referencing
.... extension I0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
.... reference SΣI1..1stringPatient Reference
.... type ΣI0..1uriType the reference refers to (e.g. "Patient")
Binding: ResourceType (extensible)
.... identifier ΣI0..1IdentifierLogical reference, when literal reference is not known
.... display ΣI0..1stringText alternative for the resource
... billablePeriod ΣI0..1PeriodRelevant time frame for the claim
... created SΣI1..1dateTimeCreated DateTime
... enterer I0..1Reference(Practitioner | PractitionerRole)Author of the claim
... insurer ΣI0..1Reference(Organization)Target
... provider SΣI1..1Reference(CARIN RTPBC PharmacyOrganization)Preferred Pharmacy
.... id 0..1stringUnique id for inter-element referencing
.... extension I0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
.... reference SΣI1..1stringReference to Pharmacy Organization
.... type ΣI0..1uriType the reference refers to (e.g. "Patient")
Binding: ResourceType (extensible)
.... identifier ΣI0..1IdentifierLogical reference, when literal reference is not known
.... display ΣI0..1stringText alternative for the resource
... priority SΣI1..1CodeableConceptProcessing priority
Binding: ProcessPriorityCodes (example)
Fixed Value: As shown
.... id0..0stringUnique id for inter-element referencing
.... extension0..0ExtensionAdditional content defined by implementations
.... coding1..1CodingCode defined by a terminology system
Fixed Value: (complex)
..... id0..0stringUnique id for inter-element referencing
..... extension0..0ExtensionAdditional content defined by implementations
..... system1..1uriIdentity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/processpriority
..... version0..0stringVersion of the system - if relevant
..... code1..1codeSymbol in syntax defined by the system
Fixed Value: normal
..... display1..1stringRepresentation defined by the system
Fixed Value: Normal
..... userSelected0..0booleanIf this coding was chosen directly by the user
.... text0..0stringPlain text representation of the concept
.... id 0..1stringUnique id for inter-element referencing
.... extension I0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
.... coding SΣI1..1CodingCode defined by a terminology system
..... id 0..1stringUnique id for inter-element referencing
..... extension I0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
..... system SΣI1..1uriIdentity of the terminology system
..... version ΣI0..1stringVersion of the system - if relevant
..... code SΣI1..1codeSymbol in syntax defined by the system
..... display ΣI0..1stringRepresentation defined by the system
..... userSelected ΣI0..1booleanIf this coding was chosen directly by the user
.... text ΣI0..1stringPlain text representation of the concept
... fundsReserve I0..1CodeableConceptFor whom to reserve funds
Binding: Funds Reservation Codes (example)
... related I0..*BackboneElementPrior or corollary claims
.... id 0..1stringUnique id for inter-element referencing
.... extension I0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!ΣI0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... claim I0..1Reference(Claim)Reference to the related claim
.... relationship I0..1CodeableConceptHow the reference claim is related
Binding: ExampleRelatedClaimRelationshipCodes (example)
.... reference I0..1IdentifierFile or case reference
... prescription I1..1Reference(CARIN RTPBC Medication Request)Prescription Reference
.... id 0..1stringUnique id for inter-element referencing
.... extension I0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
.... reference ΣI1..1stringLiteral reference, Relative, internal or absolute URL
.... type ΣI0..1uriType the reference refers to (e.g. "Patient")
Binding: ResourceType (extensible)
.... identifier ΣI0..1IdentifierLogical reference, when literal reference is not known
.... display ΣI0..1stringText alternative for the resource
... originalPrescription I0..1Reference(DeviceRequest | MedicationRequest | VisionPrescription)Original prescription if superseded by fulfiller
... payee I0..1BackboneElementRecipient of benefits payable
.... id 0..1stringUnique id for inter-element referencing
.... extension I0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!ΣI0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... type I1..1CodeableConceptCategory of recipient
Binding: Claim Payee Type Codes (example)
.... party I0..1Reference(Practitioner | PractitionerRole | Organization | Patient | RelatedPerson)Recipient reference
... referral I0..1Reference(ServiceRequest)Treatment referral
... facility I0..1Reference(Location)Servicing facility
... careTeam SI1..1BackboneElementCare Team
.... id 0..1stringUnique id for inter-element referencing
.... extension I0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!ΣI0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... sequence SI1..1positiveIntOrder of care team
Fixed Value: 1
.... provider SI1..1Reference(CARIN RTPBC Practitioner)Prescriber
..... id 0..1stringUnique id for inter-element referencing
..... extension I0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
..... reference SΣI1..1stringPrescriber Reference
..... type ΣI0..1uriType the reference refers to (e.g. "Patient")
Binding: ResourceType (extensible)
..... identifier ΣI0..1IdentifierLogical reference, when literal reference is not known
..... display ΣI0..1stringText alternative for the resource
.... responsible I0..1booleanIndicator of the lead practitioner
.... role I0..1CodeableConceptFunction within the team
Binding: ClaimCareTeamRoleCodes (example)
.... qualification I0..1CodeableConceptPractitioner credential or specialization
Binding: ExampleProviderQualificationCodes (example)
... supportingInfo I0..*BackboneElementSupporting information
.... id 0..1stringUnique id for inter-element referencing
.... extension I0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!ΣI0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... sequence I1..1positiveIntInformation instance identifier
.... category I1..1CodeableConceptClassification of the supplied information
Binding: ClaimInformationCategoryCodes (example)
.... code I0..1CodeableConceptType of information
Binding: ExceptionCodes (example)
.... timing[x] I0..1When it occurred
..... timingDatedate
..... timingPeriodPeriod
.... value[x] I0..1Data to be provided
..... valueBooleanboolean
..... valueStringstring
..... valueQuantityQuantity
..... valueAttachmentAttachment
..... valueReferenceReference(Resource)
.... reason I0..1CodeableConceptExplanation for the information
Binding: MissingToothReasonCodes (example)
... diagnosis I0..*BackboneElementPertinent diagnosis information
.... id 0..1stringUnique id for inter-element referencing
.... extension I0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!ΣI0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... sequence I1..1positiveIntDiagnosis instance identifier
.... diagnosis[x] I1..1Nature of illness or problem
Binding: ICD-10Codes (example)
..... diagnosisCodeableConceptCodeableConcept
..... diagnosisReferenceReference(Condition)
.... type I0..*CodeableConceptTiming or nature of the diagnosis
Binding: ExampleDiagnosisTypeCodes (example)
.... onAdmission I0..1CodeableConceptPresent on admission
Binding: ExampleDiagnosisOnAdmissionCodes (example)
.... packageCode I0..1CodeableConceptPackage billing code
Binding: ExampleDiagnosisRelatedGroupCodes (example)
... procedure I0..*BackboneElementClinical procedures performed
.... id 0..1stringUnique id for inter-element referencing
.... extension I0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!ΣI0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... sequence I1..1positiveIntProcedure instance identifier
.... type I0..*CodeableConceptCategory of Procedure
Binding: ExampleProcedureTypeCodes (example)
.... date I0..1dateTimeWhen the procedure was performed
.... procedure[x] I1..1Specific clinical procedure
Binding: ICD-10ProcedureCodes (example)
..... procedureCodeableConceptCodeableConcept
..... procedureReferenceReference(Procedure)
.... udi I0..*Reference(Device)Unique device identifier
... insurance SΣI1..1BackboneElementPharmacy Coverage
.... id 0..1stringUnique id for inter-element referencing
.... extension I0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!ΣI0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... sequence SΣI1..1positiveIntInsurance instance identifier
Fixed Value: 1
.... focal SΣI1..1booleanCoverage to be used for adjudication
Fixed Value: true
.... identifier I0..1IdentifierPre-assigned Claim number
.... coverage SΣI1..1Reference(CARIN RTPBC Coverage)Pharmacy Coverage Reference
..... id 0..1stringUnique id for inter-element referencing
..... extension I0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
..... reference SΣI1..1stringPharmacy Coverage Reference
..... type ΣI0..1uriType the reference refers to (e.g. "Patient")
Binding: ResourceType (extensible)
..... identifier ΣI0..1IdentifierLogical reference, when literal reference is not known
..... display ΣI0..1stringText alternative for the resource
.... businessArrangement I0..1stringAdditional provider contract number
.... preAuthRef I0..*stringPrior authorization reference number
.... claimResponse I0..1Reference(ClaimResponse)Adjudication results
... accident I0..1BackboneElementDetails of the event
.... id 0..1stringUnique id for inter-element referencing
.... extension I0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!ΣI0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... date I1..1dateWhen the incident occurred
.... type I0..1CodeableConceptThe nature of the accident
Binding: V3 Value SetActIncidentCode (extensible)
.... location[x] I0..1Where the event occurred
..... locationAddressAddress
..... locationReferenceReference(Location)
... item SI1..1BackboneElementMax 1 item per request
.... id 0..1stringUnique id for inter-element referencing
.... extension I0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!ΣI0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... sequence SI1..1positiveIntItem instance identifier
Fixed Value: 1
.... careTeamSequence SI1..1positiveIntCare Team Sequence ID Reference
.... diagnosisSequence I0..*positiveIntApplicable diagnoses
.... procedureSequence I0..*positiveIntApplicable procedures
.... informationSequence I0..*positiveIntApplicable exception and supporting information
.... revenue I0..1CodeableConceptRevenue or cost center code
Binding: ExampleRevenueCenterCodes (example)
.... category I0..1CodeableConceptBenefit classification
Binding: BenefitCategoryCodes (example)
.... productOrService SI1..1CodeableConceptPrescribed Product
Binding: CARIN RTPBC Prescribable Product Code Value Set (extensible)
..... id 0..1stringUnique id for inter-element referencing
..... extension I0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
..... coding SΣI1..*CodingCode defined by a terminology system
...... id 0..1stringUnique id for inter-element referencing
...... extension I0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
...... system SΣI1..1uriIdentity of the terminology system
...... version ΣI0..1stringVersion of the system - if relevant
...... code SΣI1..1codeSymbol in syntax defined by the system
...... display SΣI1..1stringProduct Description
...... userSelected ΣI0..1booleanIf this coding was chosen directly by the user
..... text ΣI0..1stringPlain text representation of the concept
.... modifier I0..*CodeableConceptProduct or service billing modifiers
Binding: ModifierTypeCodes (example)
.... programCode I0..*CodeableConceptProgram the product or service is provided under
Binding: ExampleProgramReasonCodes (example)
.... serviced[x] I0..1Date or dates of service or product delivery
..... servicedDatedate
..... servicedPeriodPeriod
.... location[x] I0..1Place of service or where product was supplied
Binding: ExampleServicePlaceCodes (example)
..... locationCodeableConceptCodeableConcept
..... locationAddressAddress
..... locationReferenceReference(Location)
.... quantity SI1..1SimpleQuantityPrescribed Quantity
..... id 0..1stringUnique id for inter-element referencing
..... extension I0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
..... value SΣI1..1decimalQuantity in Billing Units
..... unit SΣI1..1stringBilling unit of measure
Binding: CARIN RTPBC Billing Unit Value Set (extensible)
..... system ΣI0..1uriSystem that defines coded unit form
..... code ΣI0..1codeCoded form of the unit
.... unitPrice I0..1MoneyFee, charge or cost per item
.... factor I0..1decimalPrice scaling factor
.... net I0..1MoneyTotal item cost
.... udi I0..*Reference(Device)Unique device identifier
.... bodySite I0..1CodeableConceptAnatomical location
Binding: OralSiteCodes (example)
.... subSite I0..*CodeableConceptAnatomical sub-location
Binding: SurfaceCodes (example)
.... encounter I0..*Reference(Encounter)Encounters related to this billed item
.... detail I0..*BackboneElementProduct or service provided
..... id 0..1stringUnique id for inter-element referencing
..... extension I0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!ΣI0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... sequence I1..1positiveIntItem instance identifier
..... revenue I0..1CodeableConceptRevenue or cost center code
Binding: ExampleRevenueCenterCodes (example)
..... category I0..1CodeableConceptBenefit classification
Binding: BenefitCategoryCodes (example)
..... productOrService I1..1CodeableConceptBilling, service, product, or drug code
Binding: USCLSCodes (example)
..... modifier I0..*CodeableConceptService/Product billing modifiers
Binding: ModifierTypeCodes (example)
..... programCode I0..*CodeableConceptProgram the product or service is provided under
Binding: ExampleProgramReasonCodes (example)
..... quantity I0..1SimpleQuantityCount of products or services
..... unitPrice I0..1MoneyFee, charge or cost per item
..... factor I0..1decimalPrice scaling factor
..... net I0..1MoneyTotal item cost
..... udi I0..*Reference(Device)Unique device identifier
..... subDetail I0..*BackboneElementProduct or service provided
...... id 0..1stringUnique id for inter-element referencing
...... extension I0..*ExtensionAdditional content defined by implementations
...... modifierExtension ?!ΣI0..*ExtensionExtensions that cannot be ignored even if unrecognized
...... sequence I1..1positiveIntItem instance identifier
...... revenue I0..1CodeableConceptRevenue or cost center code
Binding: ExampleRevenueCenterCodes (example)
...... category I0..1CodeableConceptBenefit classification
Binding: BenefitCategoryCodes (example)
...... productOrService I1..1CodeableConceptBilling, service, product, or drug code
Binding: USCLSCodes (example)
...... modifier I0..*CodeableConceptService/Product billing modifiers
Binding: ModifierTypeCodes (example)
...... programCode I0..*CodeableConceptProgram the product or service is provided under
Binding: ExampleProgramReasonCodes (example)
...... quantity I0..1SimpleQuantityCount of products or services
...... unitPrice I0..1MoneyFee, charge or cost per item
...... factor I0..1decimalPrice scaling factor
...... net I0..1MoneyTotal item cost
...... udi I0..*Reference(Device)Unique device identifier
... total I0..1MoneyTotal claim cost

doco Documentation for this format

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