# RTPBC Request Using Claim - Non-PHI - Consumer Real-Time Pharmacy Benefit Check FHIR IG v2.0.0

## Resource Profile: RTPBC Request Using Claim - Non-PHI 

 
This profile provides minimal, non-persoanlly-identifiable content for submission in an RTPBC request to data sources that can provide benefit or price information without receiving patient details. 

**Usages:**

* Use this Profile: [RTPBC Request Bundle - Non-PHI](StructureDefinition-rtpbc-request-bundle-non-phi.md)
* Examples for this Profile: [Claim/rtpbc-claim-non-phi-1](Claim-rtpbc-claim-non-phi-1.md) and [Claim/rtpbc-claim-non-phi-2](Claim-rtpbc-claim-non-phi-2.md)

You can also check for [usages in the FHIR IG Statistics](https://packages2.fhir.org/xig/hl7.fhir.us.carin-rtpbc|current/StructureDefinition/rtpbc-request-claim-non-phi)

### Formal Views of Profile Content

 [Description Differentials, Snapshots, and other representations](http://build.fhir.org/ig/FHIR/ig-guidance/readingIgs.html#structure-definitions). 

 

Other representations of profile: [CSV](../StructureDefinition-rtpbc-request-claim-non-phi.csv), [Excel](../StructureDefinition-rtpbc-request-claim-non-phi.xlsx), [Schematron](../StructureDefinition-rtpbc-request-claim-non-phi.sch) 



## Resource Content

```json
{
  "resourceType" : "StructureDefinition",
  "id" : "rtpbc-request-claim-non-phi",
  "extension" : [
    {
      "url" : "http://hl7.org/fhir/StructureDefinition/structuredefinition-wg",
      "valueCode" : "phx"
    },
    {
      "url" : "http://hl7.org/fhir/StructureDefinition/structuredefinition-fmm",
      "valueInteger" : 4,
      "_valueInteger" : {
        "extension" : [
          {
            "url" : "http://hl7.org/fhir/StructureDefinition/structuredefinition-conformance-derivedFrom",
            "valueCanonical" : "http://hl7.org/fhir/us/carin-rtpbc/ImplementationGuide/hl7.fhir.us.carin-rtpbc"
          }
        ]
      }
    },
    {
      "url" : "http://hl7.org/fhir/StructureDefinition/structuredefinition-standards-status",
      "valueCode" : "trial-use",
      "_valueCode" : {
        "extension" : [
          {
            "url" : "http://hl7.org/fhir/StructureDefinition/structuredefinition-conformance-derivedFrom",
            "valueCanonical" : "http://hl7.org/fhir/us/carin-rtpbc/ImplementationGuide/hl7.fhir.us.carin-rtpbc"
          }
        ]
      }
    }
  ],
  "url" : "http://hl7.org/fhir/us/carin-rtpbc/StructureDefinition/rtpbc-request-claim-non-phi",
  "version" : "2.0.0",
  "name" : "RtpbcRequestClaimNonPHI",
  "title" : "RTPBC Request Using Claim - Non-PHI",
  "status" : "active",
  "date" : "2025-12-12T00:00:00-05:00",
  "publisher" : "HL7 International / Pharmacy",
  "contact" : [
    {
      "name" : "HL7 International / Pharmacy",
      "telecom" : [
        {
          "system" : "url",
          "value" : "http://www.hl7.org/Special/committees/medication"
        }
      ]
    },
    {
      "name" : "Frank McKinney",
      "telecom" : [
        {
          "system" : "email",
          "value" : "fm@frankmckinney.com"
        }
      ]
    }
  ],
  "description" : "This profile provides minimal, non-persoanlly-identifiable content for submission in an RTPBC request to data sources that can provide benefit or price information without receiving patient details.",
  "jurisdiction" : [
    {
      "coding" : [
        {
          "system" : "urn:iso:std:iso:3166",
          "code" : "US",
          "display" : "United States of America"
        }
      ]
    }
  ],
  "fhirVersion" : "4.0.1",
  "mapping" : [
    {
      "identity" : "workflow",
      "uri" : "http://hl7.org/fhir/workflow",
      "name" : "Workflow Pattern"
    },
    {
      "identity" : "w5",
      "uri" : "http://hl7.org/fhir/fivews",
      "name" : "FiveWs Pattern Mapping"
    },
    {
      "identity" : "rim",
      "uri" : "http://hl7.org/v3",
      "name" : "RIM Mapping"
    }
  ],
  "kind" : "resource",
  "abstract" : false,
  "type" : "Claim",
  "baseDefinition" : "http://hl7.org/fhir/StructureDefinition/Claim",
  "derivation" : "constraint",
  "differential" : {
    "element" : [
      {
        "id" : "Claim.id",
        "path" : "Claim.id",
        "label" : "Unique Claim Resource Identifier",
        "short" : "Unique Claim Resource Identifier",
        "definition" : "Unique Claim Resource Identifier assigned by the submitting patient application",
        "min" : 1,
        "mustSupport" : true
      },
      {
        "id" : "Claim.identifier",
        "path" : "Claim.identifier",
        "label" : "RTPBC request identifier",
        "short" : "RTPBC request identifier",
        "min" : 1,
        "max" : "1",
        "mustSupport" : true
      },
      {
        "id" : "Claim.identifier.value",
        "path" : "Claim.identifier.value",
        "label" : "Unique RTPBC request ID",
        "short" : "Unique RTPBC request ID",
        "definition" : "An identifier for each RTPBC request that is assigned by and unique to the submitter",
        "min" : 1,
        "mustSupport" : true
      },
      {
        "id" : "Claim.status",
        "path" : "Claim.status",
        "label" : "Request status",
        "short" : "Request status",
        "definition" : "The status of this request (active)",
        "comment" : "Value is always 'active'",
        "fixedCode" : "active",
        "mustSupport" : true
      },
      {
        "id" : "Claim.type",
        "path" : "Claim.type",
        "label" : "Requested Service Type",
        "short" : "Requested Service Type",
        "definition" : "The type of service for which pricing and coverage predetermination is being requested",
        "comment" : "Value is always 'pharmacy'",
        "mustSupport" : true
      },
      {
        "id" : "Claim.type.coding",
        "path" : "Claim.type.coding",
        "min" : 1,
        "max" : "1",
        "mustSupport" : true
      },
      {
        "id" : "Claim.type.coding.system",
        "path" : "Claim.type.coding.system",
        "min" : 1,
        "fixedUri" : "http://terminology.hl7.org/CodeSystem/claim-type",
        "mustSupport" : true
      },
      {
        "id" : "Claim.type.coding.code",
        "path" : "Claim.type.coding.code",
        "min" : 1,
        "fixedCode" : "pharmacy",
        "mustSupport" : true
      },
      {
        "id" : "Claim.type.coding.display",
        "path" : "Claim.type.coding.display",
        "min" : 1,
        "fixedString" : "Pharmacy",
        "mustSupport" : true
      },
      {
        "id" : "Claim.use",
        "path" : "Claim.use",
        "label" : "Processing Mode",
        "short" : "Processing Mode",
        "definition" : "The mode of processing being requested of the payer/PBM",
        "comment" : "Value is always 'predetermination'",
        "fixedCode" : "predetermination",
        "mustSupport" : true
      },
      {
        "id" : "Claim.patient",
        "path" : "Claim.patient",
        "label" : "Request Patient Information",
        "short" : "Request Patient Information",
        "definition" : "No PHI is sent in this Patient profile",
        "type" : [
          {
            "code" : "Reference",
            "targetProfile" : [
              "http://hl7.org/fhir/us/carin-rtpbc/StructureDefinition/rtpbc-patient-non-phi"
            ]
          }
        ],
        "mustSupport" : true
      },
      {
        "id" : "Claim.patient.reference",
        "path" : "Claim.patient.reference",
        "label" : "Patient Reference",
        "short" : "Patient Reference",
        "definition" : "Reference to a Patient resource",
        "mustSupport" : true
      },
      {
        "id" : "Claim.created",
        "path" : "Claim.created",
        "label" : "Created DateTime",
        "short" : "Created DateTime",
        "definition" : "The date and time on which this RTBPC request was created",
        "mustSupport" : true
      },
      {
        "id" : "Claim.provider",
        "path" : "Claim.provider",
        "label" : "Preferred Pharmacy",
        "short" : "Preferred Pharmacy",
        "definition" : "The patient's preferred pharmacy to be considered during creation of the response",
        "type" : [
          {
            "code" : "Reference",
            "targetProfile" : [
              "http://hl7.org/fhir/us/carin-rtpbc/StructureDefinition/rtpbc-pharmacy-organization"
            ]
          }
        ],
        "mustSupport" : true
      },
      {
        "id" : "Claim.provider.reference",
        "path" : "Claim.provider.reference",
        "label" : "Reference to Pharmacy Organization",
        "short" : "Reference to Pharmacy Organization",
        "definition" : "Reference to an Organization resource representing the patient's preferred pharmacy",
        "mustSupport" : true
      },
      {
        "id" : "Claim.priority",
        "path" : "Claim.priority",
        "label" : "Processing priority",
        "short" : "Processing priority",
        "definition" : "The processing priority requested of the payer/PBM",
        "comment" : "All requests are responded to in real-time, without differentiated priority levels. Value is always 'normal'",
        "mustSupport" : true
      },
      {
        "id" : "Claim.priority.coding",
        "path" : "Claim.priority.coding",
        "min" : 1,
        "max" : "1",
        "mustSupport" : true
      },
      {
        "id" : "Claim.priority.coding.system",
        "path" : "Claim.priority.coding.system",
        "min" : 1,
        "fixedUri" : "http://terminology.hl7.org/CodeSystem/processpriority",
        "mustSupport" : true
      },
      {
        "id" : "Claim.priority.coding.code",
        "path" : "Claim.priority.coding.code",
        "min" : 1,
        "fixedCode" : "normal",
        "mustSupport" : true
      },
      {
        "id" : "Claim.priority.coding.display",
        "path" : "Claim.priority.coding.display",
        "min" : 1,
        "fixedString" : "Normal",
        "mustSupport" : true
      },
      {
        "id" : "Claim.prescription",
        "path" : "Claim.prescription",
        "label" : "Prescription Reference",
        "short" : "Prescription Reference",
        "definition" : "Reference to the pertinent prescription information in a MedicationRequest resource.",
        "min" : 1,
        "type" : [
          {
            "code" : "Reference",
            "targetProfile" : [
              "http://hl7.org/fhir/us/carin-rtpbc/StructureDefinition/rtpbc-medicationrequest-non-phi"
            ]
          }
        ],
        "mustSupport" : true
      },
      {
        "id" : "Claim.prescription.reference",
        "path" : "Claim.prescription.reference",
        "min" : 1,
        "mustSupport" : true
      },
      {
        "id" : "Claim.careTeam",
        "path" : "Claim.careTeam",
        "label" : "Prescriber",
        "short" : "Prescriber",
        "definition" : "Prescriber reference",
        "comment" : "The careTeam represents the specific practitioner that prescribed the medication. Thus, a single careTeam element is included in the RTPBC request",
        "requirements" : "The specific practitioner that prescribed the medication.",
        "max" : "1",
        "mustSupport" : true
      },
      {
        "id" : "Claim.careTeam.sequence",
        "path" : "Claim.careTeam.sequence",
        "fixedPositiveInt" : 1,
        "mustSupport" : true
      },
      {
        "id" : "Claim.careTeam.provider",
        "path" : "Claim.careTeam.provider",
        "label" : "Prescriber",
        "short" : "Prescriber",
        "definition" : "Prescriber of the item being submitted",
        "type" : [
          {
            "code" : "Reference",
            "targetProfile" : [
              "http://hl7.org/fhir/us/core/StructureDefinition/us-core-practitioner"
            ]
          }
        ],
        "mustSupport" : true
      },
      {
        "id" : "Claim.careTeam.provider.reference",
        "path" : "Claim.careTeam.provider.reference",
        "label" : "Prescriber Reference",
        "short" : "Prescriber Reference",
        "definition" : "Reference to a Practitioner resource that represents the prescriber",
        "mustSupport" : true
      },
      {
        "id" : "Claim.insurance",
        "path" : "Claim.insurance",
        "label" : "Pharmacy Coverage",
        "short" : "Pharmacy Coverage",
        "definition" : "The patient's pharmacy coverage information"
      },
      {
        "id" : "Claim.insurance.sequence",
        "path" : "Claim.insurance.sequence",
        "comment" : "Only one set of coverage is submitted in the request. Value is always '1'",
        "fixedPositiveInt" : 1,
        "mustSupport" : true
      },
      {
        "id" : "Claim.insurance.focal",
        "path" : "Claim.insurance.focal",
        "fixedBoolean" : true,
        "mustSupport" : true
      },
      {
        "id" : "Claim.insurance.coverage",
        "path" : "Claim.insurance.coverage",
        "label" : "Pharmacy Coverage Reference",
        "short" : "Pharmacy Coverage Reference",
        "definition" : "Reference to a Coverage resource containing identification of the patient's pharmacy coverage",
        "type" : [
          {
            "code" : "Reference",
            "targetProfile" : [
              "http://hl7.org/fhir/us/carin-rtpbc/StructureDefinition/rtpbc-coverage"
            ]
          }
        ]
      },
      {
        "id" : "Claim.insurance.coverage.reference",
        "path" : "Claim.insurance.coverage.reference",
        "label" : "Pharmacy Coverage Reference",
        "short" : "Pharmacy Coverage Reference",
        "definition" : "Reference to a Coverage resource containing identification of the patient's pharmacy coverage",
        "mustSupport" : true
      },
      {
        "id" : "Claim.item",
        "path" : "Claim.item",
        "label" : "Max 1 item per request",
        "short" : "Max 1 item per request",
        "min" : 1,
        "max" : "1",
        "mustSupport" : true
      },
      {
        "id" : "Claim.item.sequence",
        "path" : "Claim.item.sequence",
        "comment" : "A maximum of one product is submitted per request. Value is always '1'",
        "fixedPositiveInt" : 1,
        "mustSupport" : true
      },
      {
        "id" : "Claim.item.careTeamSequence",
        "path" : "Claim.item.careTeamSequence",
        "label" : "Care Team Sequence ID Reference",
        "short" : "Care Team Sequence ID Reference",
        "definition" : "A reference to the Care Team composite in this resource that reflects the prescriber",
        "comment" : "Populate with a reference to .careTeam.sequence.@id",
        "min" : 1,
        "max" : "1",
        "mustSupport" : true
      },
      {
        "id" : "Claim.item.productOrService",
        "path" : "Claim.item.productOrService",
        "label" : "Prescribed Product",
        "short" : "Prescribed Product",
        "definition" : "A product identifier for the prescribed medication. Either an NDC11 or an RxNorm code for a prescribable product (representing drug name, strength and dose form)",
        "comment" : "The NDC11 is an 11-digit normalized format consisting of a 5-digit labeler segment, 4-digit product segment, and 2-digit package segment, with no dashes",
        "mustSupport" : true,
        "binding" : {
          "strength" : "extensible",
          "description" : "RTPBC prescribable product codes (NDC11 and RxNorm)",
          "valueSet" : "http://hl7.org/fhir/us/carin-rtpbc/ValueSet/rtpbc-prescribable-product-code"
        }
      },
      {
        "id" : "Claim.item.productOrService.coding",
        "path" : "Claim.item.productOrService.coding",
        "mustSupport" : true
      },
      {
        "id" : "Claim.item.productOrService.coding.system",
        "path" : "Claim.item.productOrService.coding.system",
        "mustSupport" : true
      },
      {
        "id" : "Claim.item.productOrService.coding.code",
        "path" : "Claim.item.productOrService.coding.code",
        "mustSupport" : true
      },
      {
        "id" : "Claim.item.productOrService.coding.display",
        "path" : "Claim.item.productOrService.coding.display",
        "label" : "Product Description",
        "short" : "Product Description",
        "definition" : "The full prescribable product name, including drug name, strength and dose form. The drug name equals the brand name if the branded product is desired",
        "mustSupport" : true
      },
      {
        "id" : "Claim.item.productOrService.text",
        "path" : "Claim.item.productOrService.text",
        "mustSupport" : true
      },
      {
        "id" : "Claim.item.quantity",
        "path" : "Claim.item.quantity",
        "label" : "Prescribed Quantity",
        "short" : "Prescribed Quantity",
        "min" : 1,
        "mustSupport" : true
      },
      {
        "id" : "Claim.item.quantity.value",
        "path" : "Claim.item.quantity.value",
        "label" : "Quantity in Billing Units",
        "short" : "Quantity in Billing Units",
        "definition" : "The prescribed quantity in terms of the applicable billing unit of measure",
        "min" : 1,
        "mustSupport" : true
      },
      {
        "id" : "Claim.item.quantity.unit",
        "path" : "Claim.item.quantity.unit",
        "label" : "Billing unit of measure",
        "short" : "Billing unit of measure",
        "definition" : "Pharmacy metric billing unit: GM (gram), ML (milliliter) or EA (each)",
        "min" : 1,
        "mustSupport" : true,
        "binding" : {
          "strength" : "extensible",
          "description" : "Billing quantity unit of measure",
          "valueSet" : "http://hl7.org/fhir/us/carin-rtpbc/ValueSet/rtpbc-billing-unit"
        }
      }
    ]
  }
}

```
