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

## : rtpbc-claim-response-03

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    {
      "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"
              }
            }
          ]
        }
      ]
    }