Consumer Real-Time Pharmacy Benefit Check FHIR IG
2.0.0 - CI Build
Consumer Real-Time Pharmacy Benefit Check FHIR IG
2.0.0 - CI Build
Consumer Real-Time Pharmacy Benefit Check FHIR IG, published by HL7 International / Pharmacy. This guide is not an authorized publication; it is the continuous build for version 2.0.0 built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/HL7/carin-rtpbc/ and changes regularly. See the Directory of published versions
<Bundle xmlns="http://hl7.org/fhir">
<id value="rtpbc-bundle-response-03"/>
<meta>
<profile
value="http://hl7.org/fhir/us/carin-rtpbc/StructureDefinition/rtpbc-response-bundle"/>
</meta>
<language value="en"/>
<type value="message"/>
<timestamp value="2019-11-15T13:10:15-05:00"/>
<entry>
<fullUrl
value="http://example.org/my-app/MessageHeader/rtpbc-messageheader-response-03wh"/>
<resource>
<MessageHeader>
<id value="rtpbc-messageheader-response-03wh"/>
<meta>
<profile
value="http://hl7.org/fhir/us/carin-rtpbc/StructureDefinition/rtpbc-response-messageheader"/>
</meta>
<language value="en"/>
<text>
<status value="generated"/>
<div xmlns="http://www.w3.org/1999/xhtml"><a name="MessageHeader_rtpbc-messageheader-response-03wh"> </a><p class="res-header-id"><b>Generated Narrative: MessageHeader rtpbc-messageheader-response-03wh</b></p><a name="rtpbc-messageheader-response-03wh"> </a><a name="hcrtpbc-messageheader-response-03wh"> </a><div style="display: inline-block; background-color: #d9e0e7; padding: 6px; margin: 4px; border: 1px solid #8da1b4; border-radius: 5px; line-height: 60%"><p style="margin-bottom: 0px"/><p style="margin-bottom: 0px">Profile: <a href="StructureDefinition-rtpbc-response-messageheader.html">RTPBC Response MessageHeader</a></p></div><p><b>event</b>: <a href="CodeSystem-rtpbc-event-type.html#rtpbc-event-type-rtpbc-response">RTPBC Event Type Code System: rtpbc-response</a> (RTPBC Response)</p><h3>Sources</h3><table class="grid"><tr><td style="display: none">-</td><td><b>Name</b></td><td><b>Endpoint</b></td></tr><tr><td style="display: none">*</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 style="display: none">-</td><td><b>Identifier</b></td><td><b>Code</b></td></tr><tr><td style="display: none">*</td><td>rtpbc-messageheader-request-03</td><td>OK</td></tr></table><p><b>focus</b>: <a href="Bundle-rtpbc-bundle-response-03.html#http-//example.org/my-app/ClaimResponse/rtpbc-claim-response-03wh">ClaimResponse: identifier = rtpbc-03-response; status = active; type = Pharmacy; use = predetermination; created = 2019-11-01 11:20:59-0500; outcome = complete; disposition = Processed successfully</a></p><p><b>definition</b>: <a href="MessageDefinition-rtpbc-response.html">RTPBC Response Message Definition</a></p></div>
</text>
<eventCoding>
<system
value="http://hl7.org/fhir/us/carin-rtpbc/CodeSystem/rtpbc-event-type"/>
<code value="rtpbc-response"/>
<display value="RTPBC Response"/>
</eventCoding>
<source>
<name value="PharmacyBenefitsCompany"/>
<endpoint value="http://example.org/PharmacyBenefitsCo/fhir"/>
</source>
<response>
<identifier value="rtpbc-messageheader-request-03"/>
<code value="ok"/>
</response>
<focus>
<reference
value="http://example.org/my-app/ClaimResponse/rtpbc-claim-response-03wh"/>
</focus>
<definition
value="http://hl7.org/fhir/us/carin-rtpbc/MessageDefinition/rtpbc-response"/>
</MessageHeader>
</resource>
</entry>
<entry>
<fullUrl
value="http://example.org/my-app/ClaimResponse/rtpbc-claim-response-03wh"/>
<resource>
<ClaimResponse>
<id value="rtpbc-claim-response-03wh"/>
<meta>
<profile
value="http://hl7.org/fhir/us/carin-rtpbc/StructureDefinition/rtpbc-response-claimresponse"/>
</meta>
<language value="en"/>
<text>
<status value="extensions"/>
<div xmlns="http://www.w3.org/1999/xhtml"><a name="ClaimResponse_rtpbc-claim-response-03wh"> </a><p class="res-header-id"><b>Generated Narrative: ClaimResponse rtpbc-claim-response-03wh</b></p><a name="rtpbc-claim-response-03wh"> </a><a name="hcrtpbc-claim-response-03wh"> </a><div style="display: inline-block; background-color: #d9e0e7; padding: 6px; margin: 4px; border: 1px solid #8da1b4; border-radius: 5px; line-height: 60%"><p style="margin-bottom: 0px"/><p style="margin-bottom: 0px">Profile: <a href="StructureDefinition-rtpbc-response-claimresponse.html">RTPBC Response Using ClaimResponse</a></p></div><p><b>identifier</b>: rtpbc-03-response</p><p><b>status</b>: Active</p><p><b>type</b>: <span title="Codes:{http://terminology.hl7.org/CodeSystem/claim-type pharmacy}">Pharmacy</span></p><p><b>use</b>: Predetermination</p><p><b>patient</b>: <a href="Patient-rtpbc-patient-03.html">Jane Doe Female, DoB: 1975-12-05 ( Patient internal identifier: 30455)</a></p><p><b>created</b>: 2019-11-01 11:20:59-0500</p><p><b>insurer</b>: Identifier: Pharmacy Plans US</p><p><b>request</b>: Identifier: rtpbc-03</p><p><b>outcome</b>: Processing Complete</p><p><b>disposition</b>: Processed successfully</p><blockquote><p><b>item</b></p><p><b>RTPBC benefitRestriction Extension</b>: <a href="CodeSystem-rtpbc-benefit-restriction.html#rtpbc-benefit-restriction-prior-auth">RTPBC Benefit Restriction Code System: prior-auth</a> (Prior authorization required)</p><p><b>itemSequence</b>: 1</p><blockquote><p><b>adjudication</b></p><p><b>category</b>: <span title="Codes:{http://hl7.org/fhir/us/carin-rtpbc/CodeSystem/rtpbc-patient-pay-type copay}">Copay</span></p><h3>Amounts</h3><table class="grid"><tr><td style="display: none">-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td style="display: none">*</td><td>40</td><td>United States dollar</td></tr></table></blockquote><blockquote><p><b>adjudication</b></p><p><b>category</b>: <span title="Codes:{http://hl7.org/fhir/us/carin-rtpbc/CodeSystem/rtpbc-patient-pay-type coinsurance}">Per prescription coinsurance</span></p><h3>Amounts</h3><table class="grid"><tr><td style="display: none">-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td style="display: none">*</td><td>30</td><td>United States dollar</td></tr></table></blockquote><blockquote><p><b>adjudication</b></p><p><b>category</b>: <span title="Codes:{http://hl7.org/fhir/us/carin-rtpbc/CodeSystem/rtpbc-patient-pay-type total}">Total patient responsibility</span></p><h3>Amounts</h3><table class="grid"><tr><td style="display: none">-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td style="display: none">*</td><td>70</td><td>United States dollar</td></tr></table></blockquote></blockquote><blockquote><p><b>addItem</b></p><p><b>RTPBC isAlternative Extension</b>: true</p><p><b>RTPBC benefitRestriction Extension</b>: <a href="CodeSystem-rtpbc-benefit-restriction.html#rtpbc-benefit-restriction-covered">RTPBC Benefit Restriction Code System: covered</a> (Covered)</p><p><b>itemSequence</b>: 1</p><p><b>provider</b>: <a href="Organization-rtpbc-organization-03m.html">Organization My Mail Service Pharmacy</a></p><p><b>productOrService</b>: <span title="Codes:{http://www.nlm.nih.gov/research/umls/rxnorm 205535}">fluoxetine 10 MG Oral Capsule [Prozac]</span></p><p><b>quantity</b>: 180 {Each}</p><blockquote><p><b>adjudication</b></p><p><b>category</b>: <span title="Codes:{http://hl7.org/fhir/us/carin-rtpbc/CodeSystem/rtpbc-patient-pay-type copay}">Copay</span></p><h3>Amounts</h3><table class="grid"><tr><td style="display: none">-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td style="display: none">*</td><td>20</td><td>United States dollar</td></tr></table></blockquote><blockquote><p><b>adjudication</b></p><p><b>category</b>: <span title="Codes:{http://hl7.org/fhir/us/carin-rtpbc/CodeSystem/rtpbc-patient-pay-type coinsurance}">Per prescription coinsurance</span></p><h3>Amounts</h3><table class="grid"><tr><td style="display: none">-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td style="display: none">*</td><td>30</td><td>United States dollar</td></tr></table></blockquote><blockquote><p><b>adjudication</b></p><p><b>category</b>: <span title="Codes:{http://hl7.org/fhir/us/carin-rtpbc/CodeSystem/rtpbc-patient-pay-type total}">Total patient responsibility</span></p><h3>Amounts</h3><table class="grid"><tr><td style="display: none">-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td style="display: none">*</td><td>50</td><td>United States dollar</td></tr></table></blockquote></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>
<extension
url="http://hl7.org/fhir/us/carin-rtpbc/StructureDefinition/rtpbc-benefitRestriction">
<valueCoding>
<system
value="http://hl7.org/fhir/us/carin-rtpbc/CodeSystem/rtpbc-benefit-restriction"/>
<code value="prior-auth"/>
<display value="Prior authorization required"/>
</valueCoding>
</extension>
<itemSequence value="1"/>
<adjudication>
<category>
<coding>
<system
value="http://hl7.org/fhir/us/carin-rtpbc/CodeSystem/rtpbc-patient-pay-type"/>
<code value="copay"/>
<display value="Copay"/>
</coding>
</category>
<amount>
<value value="40"/>
<currency value="USD"/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system
value="http://hl7.org/fhir/us/carin-rtpbc/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-rtpbc/CodeSystem/rtpbc-patient-pay-type"/>
<code value="total"/>
<display value="Total patient responsibility"/>
</coding>
</category>
<amount>
<value value="70"/>
<currency value="USD"/>
</amount>
</adjudication>
</item>
<addItem>
<extension
url="http://hl7.org/fhir/us/carin-rtpbc/StructureDefinition/rtpbc-isAlternative">
<valueBoolean value="true"/>
</extension>
<extension
url="http://hl7.org/fhir/us/carin-rtpbc/StructureDefinition/rtpbc-benefitRestriction">
<valueCoding>
<system
value="http://hl7.org/fhir/us/carin-rtpbc/CodeSystem/rtpbc-benefit-restriction"/>
<code value="covered"/>
<display value="Covered"/>
</valueCoding>
</extension>
<itemSequence value="1"/>
<provider>🔗
<reference value="Organization/rtpbc-organization-03m"/>
</provider>
<productOrService>
<coding>
<system value="http://www.nlm.nih.gov/research/umls/rxnorm"/>
<code value="205535"/>
<display value="fluoxetine 10 MG Oral Capsule [Prozac]"/>
</coding>
</productOrService>
<quantity>
<value value="180"/>
<unit value="{Each}"/>
</quantity>
<adjudication>
<category>
<coding>
<system
value="http://hl7.org/fhir/us/carin-rtpbc/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-rtpbc/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-rtpbc/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>
</ClaimResponse>
</resource>
</entry>
<entry>
<fullUrl value="http://example.org/my-app/Patient/rtpbc-patient-03"/>
<resource>
<Patient>
<id value="rtpbc-patient-03"/>
<meta>
<profile
value="http://hl7.org/fhir/us/carin-rtpbc/StructureDefinition/rtpbc-patient"/>
</meta>
<language value="en"/>
<text>
<status value="generated"/>
<div xmlns="http://www.w3.org/1999/xhtml"><a name="Patient_rtpbc-patient-03"> </a><p class="res-header-id"><b>Generated Narrative: Patient rtpbc-patient-03</b></p><a name="rtpbc-patient-03"> </a><a name="hcrtpbc-patient-03"> </a><div style="display: inline-block; background-color: #d9e0e7; padding: 6px; margin: 4px; border: 1px solid #8da1b4; border-radius: 5px; line-height: 60%"><p style="margin-bottom: 0px"/><p style="margin-bottom: 0px">Profile: <a href="StructureDefinition-rtpbc-patient.html">RTPBC Patient</a></p></div><p style="border: 1px #661aff solid; background-color: #e6e6ff; padding: 10px;">Jane Doe Female, DoB: 1975-12-05 ( Patient internal identifier: 30455)</p><hr/><table class="grid"><tr><td style="background-color: #f3f5da" title="Ways to contact the Patient">Contact Detail</td><td colspan="3">100 Oak Court Madison WI 53510 US </td></tr></table></div>
</text>
<identifier>
<type>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/v2-0203"/>
<code value="PI"/>
<display value="Patient internal identifier"/>
</coding>
<text value="Patient internal identifier"/>
</type>
<system value="http://example.org/MyPatientApp"/>
<value value="30455"/>
</identifier>
<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/my-app/Organization/rtpbc-organization-03m"/>
<resource>
<Organization>
<id value="rtpbc-organization-03m"/>
<meta>
<profile
value="http://hl7.org/fhir/us/carin-rtpbc/StructureDefinition/rtpbc-pharmacy-organization"/>
</meta>
<language value="en"/>
<text>
<status value="generated"/>
<div xmlns="http://www.w3.org/1999/xhtml"><a name="Organization_rtpbc-organization-03m"> </a><p class="res-header-id"><b>Generated Narrative: Organization rtpbc-organization-03m</b></p><a name="rtpbc-organization-03m"> </a><a name="hcrtpbc-organization-03m"> </a><div style="display: inline-block; background-color: #d9e0e7; padding: 6px; margin: 4px; border: 1px solid #8da1b4; border-radius: 5px; line-height: 60%"><p style="margin-bottom: 0px"/><p style="margin-bottom: 0px">Profile: <a href="StructureDefinition-rtpbc-pharmacy-organization.html">RTPBC Pharmacy Organization</a></p></div><p><b>identifier</b>: <a href="http://terminology.hl7.org/5.5.0/NamingSystem-NCPDPProviderIdentificationNumber.html" title="A NCPDP assigned number that provides pharmacies with a unique, 7-digit national identifying number that assists pharmacies in their interactions with federal agencies and third party providers. The NCPDP Provider Identification Number was formerly known as the NABP (National Board of Pharmacy) number. NCPDP also enumerates licensed dispensing sites in the United States as part of its Alternate Site Enumeration Program Numbering System (ASEP). The purpose of this system is to enable a site to identify itself to all third party processors by one standard number, in order to adjudicate claims and receive reimbursement from prescription card programs.">NCPDP Provider Identification Number</a>/0999029</p><p><b>active</b>: true</p><p><b>type</b>: <span title="Codes:{http://terminology.hl7.org/CodeSystem/NCPDPPharmacyType M}">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>
</text>
<identifier>
<system
value="http://terminology.hl7.org/CodeSystem/NCPDPProviderIdentificationNumber"/>
<value value="0999029"/>
</identifier>
<active value="true"/>
<type>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/NCPDPPharmacyType"/>
<code value="M"/>
<display value="Mail Order"/>
</coding>
</type>
<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>
IG © 2024+ HL7 International / Pharmacy.
Package hl7.fhir.us.carin-rtpbc#2.0.0 based on FHIR 4.0.1.
Generated
2025-12-16
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