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
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<ClaimResponse xmlns="http://hl7.org/fhir">
<id value="rtpbc-claim-response-03-price-source"/>
<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"><p class="res-header-id"><b>Generated Narrative: ClaimResponse rtpbc-claim-response-03-price-source</b></p><a name="rtpbc-claim-response-03-price-source"> </a><a name="hcrtpbc-claim-response-03-price-source"> </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-price-source</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-03ps.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: GoodPricing</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>itemSequence</b>: 1</p><p><b>noteNumber</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 cash-price}">Full product cash price</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>105</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 coupon-discount}">Coupon discount amount</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 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>85</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>itemSequence</b>: 1</p><p><b>provider</b>: <a href="Organization-rtpbc-organization-03ps.html">Organization Home Drugs</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>: 60 {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 cash-price}">Full product cash price</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><p><b>adjudication</b></p><p><b>category</b>: <span title="Codes:{http://hl7.org/fhir/us/carin-rtpbc/CodeSystem/rtpbc-patient-pay-type coupon-discount}">Coupon discount amount</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>-10</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>40</td><td>United States dollar</td></tr></table></blockquote></blockquote></div>
</text>
<identifier>
<value value="rtpbc-03-response-price-source"/>
</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-03ps"/>
</patient>
<created value="2019-11-01T11:20:59-05:00"/>
<insurer>
<identifier>
<value value="GoodPricing"/>
</identifier>
</insurer>
<request>
<identifier>
<value value="rtpbc-03"/>
</identifier>
</request>
<outcome value="complete"/>
<disposition value="Processed successfully"/>
<item>
<itemSequence value="1"/>
<noteNumber value="1"/>
<adjudication>
<category>
<coding>
<system
value="http://hl7.org/fhir/us/carin-rtpbc/CodeSystem/rtpbc-patient-pay-type"/>
<code value="cash-price"/>
<display value="Full product cash price"/>
</coding>
</category>
<amount>
<value value="105"/>
<currency value="USD"/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system
value="http://hl7.org/fhir/us/carin-rtpbc/CodeSystem/rtpbc-patient-pay-type"/>
<code value="coupon-discount"/>
<display value="Coupon discount amount"/>
</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="total"/>
<display value="Total patient responsibility"/>
</coding>
</category>
<amount>
<value value="85"/>
<currency value="USD"/>
</amount>
</adjudication>
</item>
<addItem>
<extension
url="http://hl7.org/fhir/us/carin-rtpbc/StructureDefinition/rtpbc-isAlternative">
<valueBoolean value="true"/>
</extension>
<itemSequence value="1"/>
<provider>🔗
<reference value="Organization/rtpbc-organization-03ps"/>
</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="60"/>
<unit value="{Each}"/>
</quantity>
<adjudication>
<category>
<coding>
<system
value="http://hl7.org/fhir/us/carin-rtpbc/CodeSystem/rtpbc-patient-pay-type"/>
<code value="cash-price"/>
<display value="Full product cash price"/>
</coding>
</category>
<amount>
<value value="50"/>
<currency value="USD"/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system
value="http://hl7.org/fhir/us/carin-rtpbc/CodeSystem/rtpbc-patient-pay-type"/>
<code value="coupon-discount"/>
<display value="Coupon discount amount"/>
</coding>
</category>
<amount>
<value value="-10"/>
<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="40"/>
<currency value="USD"/>
</amount>
</adjudication>
</addItem>
</ClaimResponse>