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-bundle-response-03-w-header

Format(s):

Example RTPBC response scenario using FHIR messaging

In this example:

  • the client is a patient application
  • the server is the patient's insurer (specifically, the party that manages the patient's pharmacy benefit)
  • the response is returned as a Bundle containing a ClaimResponse and supporting resources, in response to a $process-message operation

Content:

  • the requested medication is Prozac 10mg capsule, 60 capsules, and the requested pharmacy is Hometown Drug. Adjudication returned in the ClaimResponse.item composite
  • the .item contains patient costs for the requested drug and pharmacy combination
  • the .addItem composite holds an alternative fulfillment (the requested drug at a different pharmacy). Adjudication is returned in the ClaimResponse.addItem composite
  • a pharmacy Organization resource describes the alternative pharmacy option identified by the processor
  • benefit restriction information (e.g., Covered, Covered but requiring PA) is returned in the .benefitRestriction extensions in the .item and .addItem composites

Narrative view

Bundle rtpbc-bundle-response-03-w-header of type message

Entry 1 - fullUrl = http://example.org/my-app/MessageHeader/rtpbc-messageheader-response-03wh

Resource MessageHeader:

event: RTPBC Event Type Code System rtpbc-response: RTPBC Response

Sources

-Name
*PharmacyBenefitsCompany

Responses

-IdentifierCode
*rtpbc-messageheader-request-03OK

focus: Bundle: type = message; timestamp = 2019-11-15 13:10:15-0500

definition: RTPBC Response Message Definition

Entry 2 - fullUrl = http://example.org/my-app/ClaimResponse/rtpbc-claim-response-03wh

Resource ClaimResponse:

identifier: rtpbc-03-response

status: Active

type: Pharmacy

use: Predetermination

patient: Jane Doe Female, DoB: 1975-12-05 ( Patient internal identifier: 30455)

created: 2019-11-01 11:20:59-0500

insurer: Identifier: Pharmacy Plans US

request: Identifier: rtpbc-03

outcome: complete

disposition: Processed successfully

item

RTPBC benefitRestriction Extension: RTPBC Benefit Restriction Code System prior-auth: Prior authorization required

itemSequence: 1

adjudication

category: Copay

Amounts

-ValueCurrency
*40USD

adjudication

category: Per prescription coinsurance

Amounts

-ValueCurrency
*30USD

adjudication

category: Total patient responsibility

Amounts

-ValueCurrency
*70USD

addItem

RTPBC isAlternative Extension: true

RTPBC benefitRestriction Extension: RTPBC Benefit Restriction Code System covered: Covered

itemSequence: 1

provider: Organization My Mail Service Pharmacy

productOrService: PROzac 10 MG Oral Capsule

quantity: 180 {Each}

adjudication

category: Copay

Amounts

-ValueCurrency
*20USD

adjudication

category: Per prescription coinsurance

Amounts

-ValueCurrency
*30USD

adjudication

category: Total patient responsibility

Amounts

-ValueCurrency
*50USD

Entry 3 - fullUrl = http://example.org/my-app/Patient/rtpbc-patient-03wh

Resource Patient:

Profile: RTPBC Patient

Jane Doe Female, DoB: 1975-12-05 ( Patient internal identifier: 30455)

Contact Detail100 Oak Court Madison WI 53510 US

Entry 4 - fullUrl = http://example.org/my-app/Organization/rtpbc-organization-03wh

Resource Organization:

identifier: United States National Provider Identifier/5515515515

active: true

type: Mail Order

name: My Mail Service Pharmacy

Contacts

-TelecomAddress
*ph: 555123456710001 Oakland Road Milwaukee WI 54444 US