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
<Bundle xmlns="http://hl7.org/fhir">
<id value="rtpbc-bundle-response-03-w-header"/>
<meta>
<profile
value="http://hl7.org/fhir/us/carin-rtpbc/StructureDefinition/rtpbc-response-bundle"/>
</meta>
<type value="message"/>
<timestamp value="2019-11-15T13:10:15-05:00"/>
<entry>
<fullUrl
value="http://example.org/my-app/MessageHeader/rtpbc-messageheader-response-03wh"/>
<resource>
<MessageHeader>
<id value="rtpbc-messageheader-response-03wh"/>
<meta>
<profile
value="http://hl7.org/fhir/us/carin-rtpbc/StructureDefinition/rtpbc-response-messageheader"/>
</meta>
<text>
<status value="generated"/>
<div xmlns="http://www.w3.org/1999/xhtml"><a name="MessageHeader_rtpbc-messageheader-response-03wh"> </a><p class="res-header-id"><b>Generated Narrative: MessageHeader rtpbc-messageheader-response-03wh</b></p><a name="rtpbc-messageheader-response-03wh"> </a><a name="hcrtpbc-messageheader-response-03wh"> </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"/><p style="margin-bottom: 0px">Profile: <a href="StructureDefinition-rtpbc-response-messageheader.html">RTPBC Response MessageHeader</a></p></div><p><b>event</b>: <a href="CodeSystem-rtpbc-event-type.html#rtpbc-event-type-rtpbc-response">RTPBC Event Type Code System rtpbc-response</a>: RTPBC Response</p><h3>Sources</h3><table class="grid"><tr><td style="display: none">-</td><td><b>Name</b></td><td><b>Endpoint</b></td></tr><tr><td style="display: none">*</td><td>PharmacyBenefitsCompany</td><td><a href="http://example.org/PharmacyBenefitsCo/fhir">http://example.org/PharmacyBenefitsCo/fhir</a></td></tr></table><h3>Responses</h3><table class="grid"><tr><td style="display: none">-</td><td><b>Identifier</b></td><td><b>Code</b></td></tr><tr><td style="display: none">*</td><td>rtpbc-messageheader-request-03</td><td>OK</td></tr></table><p><b>focus</b>: <a href="Bundle-rtpbc-bundle-response-03-w-header.html#http-//example.org/my-app/ClaimResponse/rtpbc-claim-response-03wh">Bundle: type = message; timestamp = 2019-11-15 13:10:15-0500</a></p><p><b>definition</b>: <a href="MessageDefinition-rtpbc-response.html">RTPBC Response Message Definition</a></p></div>
</text>
<eventCoding>
<system
value="http://hl7.org/fhir/us/carin-rtpbc/CodeSystem/rtpbc-event-type"/>
<code value="rtpbc-response"/>
<display value="RTPBC Response"/>
</eventCoding>
<source>
<name value="PharmacyBenefitsCompany"/>
<endpoint value="http://example.org/PharmacyBenefitsCo/fhir"/>
</source>
<response>
<identifier value="rtpbc-messageheader-request-03"/>
<code value="ok"/>
</response>
<focus>
<reference
value="http://example.org/my-app/ClaimResponse/rtpbc-claim-response-03wh"/>
</focus>
<definition
value="http://hl7.org/fhir/us/carin-rtpbc/MessageDefinition/rtpbc-response"/>
</MessageHeader>
</resource>
</entry>
<entry>
<fullUrl
value="http://example.org/my-app/ClaimResponse/rtpbc-claim-response-03wh"/>
<resource>
<ClaimResponse>
<id value="rtpbc-claim-response-03wh"/>
<meta>
<profile
value="http://hl7.org/fhir/us/carin-rtpbc/StructureDefinition/rtpbc-response-claimresponse"/>
</meta>
<text>
<status value="extensions"/>
<div xmlns="http://www.w3.org/1999/xhtml"><a name="ClaimResponse_rtpbc-claim-response-03wh"> </a><p class="res-header-id"><b>Generated Narrative: ClaimResponse rtpbc-claim-response-03wh</b></p><a name="rtpbc-claim-response-03wh"> </a><a name="hcrtpbc-claim-response-03wh"> </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"/><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-03wh.html">Jane Doe Female, DoB: 1975-12-05 ( Patient internal identifier: 30455)</a></p><p><b>created</b>: 2019-11-01 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>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>itemSequence</b>: 1</p><p><b>provider</b>: <a href="Organization-rtpbc-organization-03wh.html">Organization My Mail Service Pharmacy</a></p><p><b>productOrService</b>: <span title="Codes:{http://www.nlm.nih.gov/research/umls/rxnorm 205535}">PROzac 10 MG Oral Capsule</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 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>20</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>50</td><td>United States dollar</td></tr></table></blockquote></blockquote></div>
</text>
<identifier>
<value value="rtpbc-03-response"/>
</identifier>
<status value="active"/>
<type>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/claim-type"/>
<code value="pharmacy"/>
<display value="Pharmacy"/>
</coding>
</type>
<use value="predetermination"/>
<patient>🔗
<reference value="Patient/rtpbc-patient-03wh"/>
</patient>
<created value="2019-11-01T11:20:59-05:00"/>
<insurer>
<identifier>
<value value="Pharmacy Plans US"/>
</identifier>
</insurer>
<request>
<identifier>
<value value="rtpbc-03"/>
</identifier>
</request>
<outcome value="complete"/>
<disposition value="Processed successfully"/>
<item>
<extension
url="http://hl7.org/fhir/us/carin-rtpbc/StructureDefinition/rtpbc-benefitRestriction">
<valueCoding>
<system
value="http://hl7.org/fhir/us/carin-rtpbc/CodeSystem/rtpbc-benefit-restriction"/>
<code value="prior-auth"/>
<display value="Prior authorization required"/>
</valueCoding>
</extension>
<itemSequence value="1"/>
<adjudication>
<category>
<coding>
<system
value="http://hl7.org/fhir/us/carin-rtpbc/CodeSystem/rtpbc-patient-pay-type"/>
<code value="copay"/>
<display value="Copay"/>
</coding>
</category>
<amount>
<value value="40"/>
<currency value="USD"/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system
value="http://hl7.org/fhir/us/carin-rtpbc/CodeSystem/rtpbc-patient-pay-type"/>
<code value="coinsurance"/>
<display value="Per prescription coinsurance"/>
</coding>
</category>
<amount>
<value value="30"/>
<currency value="USD"/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system
value="http://hl7.org/fhir/us/carin-rtpbc/CodeSystem/rtpbc-patient-pay-type"/>
<code value="total"/>
<display value="Total patient responsibility"/>
</coding>
</category>
<amount>
<value value="70"/>
<currency value="USD"/>
</amount>
</adjudication>
</item>
<addItem>
<extension
url="http://hl7.org/fhir/us/carin-rtpbc/StructureDefinition/rtpbc-isAlternative">
<valueBoolean value="true"/>
</extension>
<extension
url="http://hl7.org/fhir/us/carin-rtpbc/StructureDefinition/rtpbc-benefitRestriction">
<valueCoding>
<system
value="http://hl7.org/fhir/us/carin-rtpbc/CodeSystem/rtpbc-benefit-restriction"/>
<code value="covered"/>
<display value="Covered"/>
</valueCoding>
</extension>
<itemSequence value="1"/>
<provider>🔗
<reference value="Organization/rtpbc-organization-03wh"/>
</provider>
<productOrService>
<coding>
<system value="http://www.nlm.nih.gov/research/umls/rxnorm"/>
<code value="205535"/>
<display value="PROzac 10 MG Oral Capsule"/>
</coding>
</productOrService>
<quantity>
<value value="180"/>
<unit value="{Each}"/>
</quantity>
<adjudication>
<category>
<coding>
<system
value="http://hl7.org/fhir/us/carin-rtpbc/CodeSystem/rtpbc-patient-pay-type"/>
<code value="copay"/>
<display value="Copay"/>
</coding>
</category>
<amount>
<value value="20"/>
<currency value="USD"/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system
value="http://hl7.org/fhir/us/carin-rtpbc/CodeSystem/rtpbc-patient-pay-type"/>
<code value="coinsurance"/>
<display value="Per prescription coinsurance"/>
</coding>
</category>
<amount>
<value value="30"/>
<currency value="USD"/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system
value="http://hl7.org/fhir/us/carin-rtpbc/CodeSystem/rtpbc-patient-pay-type"/>
<code value="total"/>
<display value="Total patient responsibility"/>
</coding>
</category>
<amount>
<value value="50"/>
<currency value="USD"/>
</amount>
</adjudication>
</addItem>
</ClaimResponse>
</resource>
</entry>
<entry>
<fullUrl value="http://example.org/my-app/Patient/rtpbc-patient-03wh"/>
<resource>
<Patient>
<id value="rtpbc-patient-03wh"/>
<meta>
<profile
value="http://hl7.org/fhir/us/carin-rtpbc/StructureDefinition/rtpbc-patient"/>
</meta>
<text>
<status value="generated"/>
<div xmlns="http://www.w3.org/1999/xhtml"><a name="Patient_rtpbc-patient-03wh"> </a><p class="res-header-id"><b>Generated Narrative: Patient rtpbc-patient-03wh</b></p><a name="rtpbc-patient-03wh"> </a><a name="hcrtpbc-patient-03wh"> </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"/><p style="margin-bottom: 0px">Profile: <a href="StructureDefinition-rtpbc-patient.html">RTPBC Patient</a></p></div><p style="border: 1px #661aff solid; background-color: #e6e6ff; padding: 10px;">Jane Doe Female, DoB: 1975-12-05 ( Patient internal identifier: 30455)</p><hr/><table class="grid"><tr><td style="background-color: #f3f5da" title="Ways to contact the Patient">Contact Detail</td><td colspan="3">100 Oak Court Madison WI 53510 US </td></tr></table></div>
</text>
<identifier>
<type>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/v2-0203"/>
<code value="PI"/>
<display value="Patient internal identifier"/>
</coding>
<text value="Patient internal identifier"/>
</type>
<system value="http://example.org/MyPatientApp"/>
<value value="30455"/>
</identifier>
<name>
<family value="Doe"/>
<given value="Jane"/>
</name>
<gender value="female"/>
<birthDate value="1975-12-05"/>
<address>
<line value="100 Oak Court"/>
<city value="Madison"/>
<state value="WI"/>
<postalCode value="53510"/>
<country value="US"/>
</address>
</Patient>
</resource>
</entry>
<entry>
<fullUrl
value="http://example.org/my-app/Organization/rtpbc-organization-03wh"/>
<resource>
<Organization>
<id value="rtpbc-organization-03wh"/>
<meta>
<profile
value="http://hl7.org/fhir/us/carin-rtpbc/StructureDefinition/rtpbc-pharmacy-organization"/>
</meta>
<text>
<status value="generated"/>
<div xmlns="http://www.w3.org/1999/xhtml"><a name="Organization_rtpbc-organization-03wh"> </a><p class="res-header-id"><b>Generated Narrative: Organization rtpbc-organization-03wh</b></p><a name="rtpbc-organization-03wh"> </a><a name="hcrtpbc-organization-03wh"> </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"/><p style="margin-bottom: 0px">Profile: <a href="StructureDefinition-rtpbc-pharmacy-organization.html">RTPBC Pharmacy Organization</a></p></div><p><b>identifier</b>: <a href="http://terminology.hl7.org/6.5.0/NamingSystem-npi.html" title="National Provider Identifier">United States National Provider Identifier</a>/5515515515</p><p><b>active</b>: true</p><p><b>type</b>: <span title="Codes:{http://terminology.hl7.org/CodeSystem/NCPDPPharmacyType M}">Mail Order</span></p><p><b>name</b>: My Mail Service Pharmacy</p><p><b>telecom</b>: ph: 5551234567</p><p><b>address</b>: 10001 Oakland Road Milwaukee WI 54444 US </p></div>
</text>
<identifier>
<system value="http://hl7.org/fhir/sid/us-npi"/>
<value value="5515515515"/>
</identifier>
<active value="true"/>
<type>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/NCPDPPharmacyType"/>
<code value="M"/>
<display value="Mail Order"/>
</coding>
</type>
<name value="My Mail Service Pharmacy"/>
<telecom>
<system value="phone"/>
<value value="5551234567"/>
</telecom>
<address>
<line value="10001 Oakland Road"/>
<city value="Milwaukee"/>
<state value="WI"/>
<postalCode value="54444"/>
<country value="US"/>
</address>
</Organization>
</resource>
</entry>
</Bundle>
IG © 2024+ HL7 International / Pharmacy. Package hl7.fhir.us.carin-rtpbc#2.0.0 based on FHIR 4.0.1. Generated 2025-08-07
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