Consumer Real-Time Pharmacy Benefit Check FHIR IG
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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

: rtpbc-claim-response-03

Page standards status: Informative

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@prefix fhir: <http://hl7.org/fhir/> .
@prefix owl: <http://www.w3.org/2002/07/owl#> .
@prefix rdf: <http://www.w3.org/1999/02/22-rdf-syntax-ns#> .
@prefix rdfs: <http://www.w3.org/2000/01/rdf-schema#> .
@prefix xsd: <http://www.w3.org/2001/XMLSchema#> .

# - resource -------------------------------------------------------------------

 a fhir:ClaimResponse ;
  fhir:nodeRole fhir:treeRoot ;
  fhir:id [ fhir:v "rtpbc-claim-response-03"] ; # 
  fhir:meta [
    ( fhir:profile [
fhir:v "http://hl7.org/fhir/us/carin-rtpbc/StructureDefinition/rtpbc-response-claimresponse"^^xsd:anyURI ;
fhir:l <http://hl7.org/fhir/us/carin-rtpbc/StructureDefinition/rtpbc-response-claimresponse>     ] )
  ] ; # 
  fhir:language [ fhir:v "en"] ; # 
  fhir:text [
fhir:status [ fhir:v "extensions" ] ;
fhir:div [ fhir:v "<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: 30455)</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>"^^rdf:XMLLiteral ]
  ] ; # 
  fhir:identifier ( [
fhir:value [ fhir:v "rtpbc-03-response" ]
  ] ) ; # 
  fhir:status [ fhir:v "active"] ; # 
  fhir:type [
    ( fhir:coding [
fhir:system [
fhir:v "http://terminology.hl7.org/CodeSystem/claim-type"^^xsd:anyURI ;
fhir:l <http://terminology.hl7.org/CodeSystem/claim-type>       ] ;
fhir:code [ fhir:v "pharmacy" ] ;
fhir:display [ fhir:v "Pharmacy" ]     ] )
  ] ; # 
  fhir:use [ fhir:v "predetermination"] ; # 
  fhir:patient [
fhir:l fhir:Patient/rtpbc-patient-03 ;
fhir:reference [ fhir:v "Patient/rtpbc-patient-03" ]
  ] ; # 
  fhir:created [ fhir:v "2025-12-11T11:20:59-05:00"^^xsd:dateTime] ; # 
  fhir:insurer [
fhir:identifier [
fhir:value [ fhir:v "Pharmacy Plans US" ]     ]
  ] ; # 
  fhir:request [
fhir:identifier [
fhir:value [ fhir:v "rtpbc-03" ]     ]
  ] ; # 
  fhir:outcome [ fhir:v "complete"] ; # 
  fhir:disposition [ fhir:v "Processed successfully"] ; # 
  fhir:item ( [
    ( fhir:extension [
fhir:url [
fhir:v "http://hl7.org/fhir/us/carin-rtpbc/StructureDefinition/rtpbc-benefitRestriction"^^xsd:anyURI ;
fhir:l <http://hl7.org/fhir/us/carin-rtpbc/StructureDefinition/rtpbc-benefitRestriction>       ] ;
fhir:value [
a fhir:Coding ;
fhir:system [
fhir:v "http://hl7.org/fhir/us/carin-rtpbc/CodeSystem/rtpbc-benefit-restriction"^^xsd:anyURI ;
fhir:l <http://hl7.org/fhir/us/carin-rtpbc/CodeSystem/rtpbc-benefit-restriction>         ] ;
fhir:code [ fhir:v "prior-auth" ] ;
fhir:display [ fhir:v "Prior authorization required" ]       ]     ] [
fhir:url [
fhir:v "http://hl7.org/fhir/us/carin-rtpbc/StructureDefinition/rtpbc-formularyStatus"^^xsd:anyURI ;
fhir:l <http://hl7.org/fhir/us/carin-rtpbc/StructureDefinition/rtpbc-formularyStatus>       ] ;
fhir:value [
a fhir:Coding ;
fhir:system [
fhir:v "http://hl7.org/fhir/us/carin-rtpbc/CodeSystem/rtpbc-formulary-status"^^xsd:anyURI ;
fhir:l <http://hl7.org/fhir/us/carin-rtpbc/CodeSystem/rtpbc-formulary-status>         ] ;
fhir:code [ fhir:v "O" ] ;
fhir:display [ fhir:v "On Formulary" ]       ]     ] [
fhir:url [
fhir:v "http://hl7.org/fhir/us/carin-rtpbc/StructureDefinition/rtpbc-preferenceLevel"^^xsd:anyURI ;
fhir:l <http://hl7.org/fhir/us/carin-rtpbc/StructureDefinition/rtpbc-preferenceLevel>       ] ;
fhir:value [
a fhir:PositiveInt ;
fhir:v "2"^^xsd:positiveInteger       ]     ] [
fhir:url [
fhir:v "http://hl7.org/fhir/us/carin-rtpbc/StructureDefinition/rtpbc-nextAvailableFillDate"^^xsd:anyURI ;
fhir:l <http://hl7.org/fhir/us/carin-rtpbc/StructureDefinition/rtpbc-nextAvailableFillDate>       ] ;
fhir:value [
a fhir:Date ;
fhir:v "2025-12-20"^^xsd:date       ]     ] ) ;
fhir:itemSequence [ fhir:v "1"^^xsd:positiveInteger ] ;
    ( fhir:adjudication [
fhir:category [
        ( fhir:coding [
fhir:system [
fhir:v "http://hl7.org/fhir/us/carin-rtpbc/CodeSystem/rtpbc-patient-pay-type"^^xsd:anyURI ;
fhir:l <http://hl7.org/fhir/us/carin-rtpbc/CodeSystem/rtpbc-patient-pay-type>           ] ;
fhir:code [ fhir:v "copay" ] ;
fhir:display [ fhir:v "Copay" ]         ] )       ] ;
fhir:amount [
fhir:value [ fhir:v "40"^^xsd:decimal ] ;
fhir:currency [ fhir:v "USD" ]       ]     ] [
fhir:category [
        ( fhir:coding [
fhir:system [
fhir:v "http://hl7.org/fhir/us/carin-rtpbc/CodeSystem/rtpbc-patient-pay-type"^^xsd:anyURI ;
fhir:l <http://hl7.org/fhir/us/carin-rtpbc/CodeSystem/rtpbc-patient-pay-type>           ] ;
fhir:code [ fhir:v "coinsurance" ] ;
fhir:display [ fhir:v "Per prescription coinsurance" ]         ] )       ] ;
fhir:amount [
fhir:value [ fhir:v "30"^^xsd:decimal ] ;
fhir:currency [ fhir:v "USD" ]       ]     ] [
fhir:category [
        ( fhir:coding [
fhir:system [
fhir:v "http://hl7.org/fhir/us/carin-rtpbc/CodeSystem/rtpbc-patient-pay-type"^^xsd:anyURI ;
fhir:l <http://hl7.org/fhir/us/carin-rtpbc/CodeSystem/rtpbc-patient-pay-type>           ] ;
fhir:code [ fhir:v "total" ] ;
fhir:display [ fhir:v "Total patient responsibility" ]         ] )       ] ;
fhir:amount [
fhir:value [ fhir:v "70"^^xsd:decimal ] ;
fhir:currency [ fhir:v "USD" ]       ]     ] )
  ] ) ; # 
  fhir:addItem ( [
    ( fhir:extension [
fhir:url [
fhir:v "http://hl7.org/fhir/us/carin-rtpbc/StructureDefinition/rtpbc-isAlternative"^^xsd:anyURI ;
fhir:l <http://hl7.org/fhir/us/carin-rtpbc/StructureDefinition/rtpbc-isAlternative>       ] ;
fhir:value [
a fhir:Boolean ;
fhir:v true       ]     ] [
fhir:url [
fhir:v "http://hl7.org/fhir/us/carin-rtpbc/StructureDefinition/rtpbc-benefitRestriction"^^xsd:anyURI ;
fhir:l <http://hl7.org/fhir/us/carin-rtpbc/StructureDefinition/rtpbc-benefitRestriction>       ] ;
fhir:value [
a fhir:Coding ;
fhir:system [
fhir:v "http://hl7.org/fhir/us/carin-rtpbc/CodeSystem/rtpbc-benefit-restriction"^^xsd:anyURI ;
fhir:l <http://hl7.org/fhir/us/carin-rtpbc/CodeSystem/rtpbc-benefit-restriction>         ] ;
fhir:code [ fhir:v "covered" ] ;
fhir:display [ fhir:v "Covered" ]       ]     ] [
fhir:url [
fhir:v "http://hl7.org/fhir/us/carin-rtpbc/StructureDefinition/rtpbc-formularyStatus"^^xsd:anyURI ;
fhir:l <http://hl7.org/fhir/us/carin-rtpbc/StructureDefinition/rtpbc-formularyStatus>       ] ;
fhir:value [
a fhir:Coding ;
fhir:system [
fhir:v "http://hl7.org/fhir/us/carin-rtpbc/CodeSystem/rtpbc-formulary-status"^^xsd:anyURI ;
fhir:l <http://hl7.org/fhir/us/carin-rtpbc/CodeSystem/rtpbc-formulary-status>         ] ;
fhir:code [ fhir:v "P" ] ;
fhir:display [ fhir:v "On Formulary/Preferred" ]       ]     ] [
fhir:url [
fhir:v "http://hl7.org/fhir/us/carin-rtpbc/StructureDefinition/rtpbc-preferenceLevel"^^xsd:anyURI ;
fhir:l <http://hl7.org/fhir/us/carin-rtpbc/StructureDefinition/rtpbc-preferenceLevel>       ] ;
fhir:value [
a fhir:PositiveInt ;
fhir:v "1"^^xsd:positiveInteger       ]     ] ) ;
    ( fhir:itemSequence [ fhir:v "1"^^xsd:positiveInteger ] ) ;
    ( fhir:provider [
fhir:l fhir:Organization/rtpbc-organization-03m ;
fhir:reference [ fhir:v "Organization/rtpbc-organization-03m" ]     ] ) ;
fhir:productOrService [
      ( fhir:coding [
fhir:system [
fhir:v "http://www.nlm.nih.gov/research/umls/rxnorm"^^xsd:anyURI ;
fhir:l <http://www.nlm.nih.gov/research/umls/rxnorm>         ] ;
fhir:code [ fhir:v "205535" ] ;
fhir:display [ fhir:v "fluoxetine 10 MG Oral Capsule [Prozac]" ]       ] )     ] ;
fhir:quantity [
fhir:value [ fhir:v "180"^^xsd:decimal ] ;
fhir:unit [ fhir:v "{Each}" ]     ] ;
    ( fhir:adjudication [
fhir:category [
        ( fhir:coding [
fhir:system [
fhir:v "http://hl7.org/fhir/us/carin-rtpbc/CodeSystem/rtpbc-patient-pay-type"^^xsd:anyURI ;
fhir:l <http://hl7.org/fhir/us/carin-rtpbc/CodeSystem/rtpbc-patient-pay-type>           ] ;
fhir:code [ fhir:v "remaining-deductible" ] ;
fhir:display [ fhir:v "Remaining deductible" ]         ] )       ] ;
fhir:amount [
fhir:value [ fhir:v "305"^^xsd:decimal ] ;
fhir:currency [ fhir:v "USD" ]       ]     ] [
fhir:category [
        ( fhir:coding [
fhir:system [
fhir:v "http://hl7.org/fhir/us/carin-rtpbc/CodeSystem/rtpbc-patient-pay-type"^^xsd:anyURI ;
fhir:l <http://hl7.org/fhir/us/carin-rtpbc/CodeSystem/rtpbc-patient-pay-type>           ] ;
fhir:code [ fhir:v "coinsurance" ] ;
fhir:display [ fhir:v "Per prescription coinsurance" ]         ] )       ] ;
fhir:amount [
fhir:value [ fhir:v "30"^^xsd:decimal ] ;
fhir:currency [ fhir:v "USD" ]       ]     ] [
fhir:category [
        ( fhir:coding [
fhir:system [
fhir:v "http://hl7.org/fhir/us/carin-rtpbc/CodeSystem/rtpbc-patient-pay-type"^^xsd:anyURI ;
fhir:l <http://hl7.org/fhir/us/carin-rtpbc/CodeSystem/rtpbc-patient-pay-type>           ] ;
fhir:code [ fhir:v "total" ] ;
fhir:display [ fhir:v "Total patient responsibility" ]         ] )       ] ;
fhir:amount [
fhir:value [ fhir:v "70"^^xsd:decimal ] ;
fhir:currency [ fhir:v "USD" ]       ]     ] )
  ] ) . #