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
| Page standards status: Informative |
{
"resourceType" : "ClaimResponse",
"id" : "rtpbc-claim-response-03",
"meta" : {
"profile" : [
🔗 "http://hl7.org/fhir/us/carin-rtpbc/StructureDefinition/rtpbc-response-claimresponse"
]
},
"language" : "en",
"text" : {
"status" : "extensions",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\" xml:lang=\"en\" lang=\"en\"><p class=\"res-header-id\"><b>Generated Narrative: ClaimResponse rtpbc-claim-response-03</b></p><a name=\"rtpbc-claim-response-03\"> </a><a name=\"hcrtpbc-claim-response-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\">Language: en</p><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:\u00a030455)</a></p><p><b>created</b>: 2025-12-11 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>RTPBC formularyStatus Extension</b>: <a href=\"CodeSystem-rtpbc-formulary-status.html#rtpbc-formulary-status-O\">RTPBC Formulary Status Code System: O</a> (On Formulary)</p><p><b>RTPBC preferenceLevel Extension</b>: 2</p><p><b>RTPBC nextAvailableFillDate Extension</b>: 2025-12-20</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>RTPBC formularyStatus Extension</b>: <a href=\"CodeSystem-rtpbc-formulary-status.html#rtpbc-formulary-status-P\">RTPBC Formulary Status Code System: P</a> (On Formulary/Preferred)</p><p><b>RTPBC preferenceLevel Extension</b>: 1</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 remaining-deductible}\">Remaining deductible</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>305</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></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" : "2025-12-11T11:20:59-05:00",
"insurer" : {
"identifier" : {
"value" : "Pharmacy Plans US"
}
},
"request" : {
"identifier" : {
"value" : "rtpbc-03"
}
},
"outcome" : "complete",
"disposition" : "Processed successfully",
"item" : [
{
"extension" : [
{
"url" : "http://hl7.org/fhir/us/carin-rtpbc/StructureDefinition/rtpbc-benefitRestriction",
"valueCoding" : {
"system" : "http://hl7.org/fhir/us/carin-rtpbc/CodeSystem/rtpbc-benefit-restriction",
"code" : "prior-auth",
"display" : "Prior authorization required"
}
},
{
"url" : "http://hl7.org/fhir/us/carin-rtpbc/StructureDefinition/rtpbc-formularyStatus",
"valueCoding" : {
"system" : "http://hl7.org/fhir/us/carin-rtpbc/CodeSystem/rtpbc-formulary-status",
"code" : "O",
"display" : "On Formulary"
}
},
{
"url" : "http://hl7.org/fhir/us/carin-rtpbc/StructureDefinition/rtpbc-preferenceLevel",
"valuePositiveInt" : 2
},
{
"url" : "http://hl7.org/fhir/us/carin-rtpbc/StructureDefinition/rtpbc-nextAvailableFillDate",
"valueDate" : "2025-12-20"
}
],
"itemSequence" : 1,
"adjudication" : [
{
"category" : {
"coding" : [
{
"system" : "http://hl7.org/fhir/us/carin-rtpbc/CodeSystem/rtpbc-patient-pay-type",
"code" : "copay",
"display" : "Copay"
}
]
},
"amount" : {
"value" : 40,
"currency" : "USD"
}
},
{
"category" : {
"coding" : [
{
"system" : "http://hl7.org/fhir/us/carin-rtpbc/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-rtpbc/CodeSystem/rtpbc-patient-pay-type",
"code" : "total",
"display" : "Total patient responsibility"
}
]
},
"amount" : {
"value" : 70,
"currency" : "USD"
}
}
]
}
],
"addItem" : [
{
"extension" : [
{
"url" : "http://hl7.org/fhir/us/carin-rtpbc/StructureDefinition/rtpbc-isAlternative",
"valueBoolean" : true
},
{
"url" : "http://hl7.org/fhir/us/carin-rtpbc/StructureDefinition/rtpbc-benefitRestriction",
"valueCoding" : {
"system" : "http://hl7.org/fhir/us/carin-rtpbc/CodeSystem/rtpbc-benefit-restriction",
"code" : "covered",
"display" : "Covered"
}
},
{
"url" : "http://hl7.org/fhir/us/carin-rtpbc/StructureDefinition/rtpbc-formularyStatus",
"valueCoding" : {
"system" : "http://hl7.org/fhir/us/carin-rtpbc/CodeSystem/rtpbc-formulary-status",
"code" : "P",
"display" : "On Formulary/Preferred"
}
},
{
"url" : "http://hl7.org/fhir/us/carin-rtpbc/StructureDefinition/rtpbc-preferenceLevel",
"valuePositiveInt" : 1
}
],
"itemSequence" : [
1
],
"provider" : [
{
🔗 "reference" : "Organization/rtpbc-organization-03m"
}
],
"productOrService" : {
"coding" : [
{
"system" : "http://www.nlm.nih.gov/research/umls/rxnorm",
"code" : "205535",
"display" : "fluoxetine 10 MG Oral Capsule [Prozac]"
}
]
},
"quantity" : {
"value" : 180,
"unit" : "{Each}"
},
"adjudication" : [
{
"category" : {
"coding" : [
{
"system" : "http://hl7.org/fhir/us/carin-rtpbc/CodeSystem/rtpbc-patient-pay-type",
"code" : "remaining-deductible",
"display" : "Remaining deductible"
}
]
},
"amount" : {
"value" : 305,
"currency" : "USD"
}
},
{
"category" : {
"coding" : [
{
"system" : "http://hl7.org/fhir/us/carin-rtpbc/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-rtpbc/CodeSystem/rtpbc-patient-pay-type",
"code" : "total",
"display" : "Total patient responsibility"
}
]
},
"amount" : {
"value" : 70,
"currency" : "USD"
}
}
]
}
]
}
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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