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-claim-response-not-covered - TTL Representation

Page standards status: Informative

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@prefix fhir: <http://hl7.org/fhir/> .
@prefix owl: <http://www.w3.org/2002/07/owl#> .
@prefix rdf: <http://www.w3.org/1999/02/22-rdf-syntax-ns#> .
@prefix rdfs: <http://www.w3.org/2000/01/rdf-schema#> .
@prefix xsd: <http://www.w3.org/2001/XMLSchema#> .

# - resource -------------------------------------------------------------------

 a fhir:ClaimResponse ;
  fhir:nodeRole fhir:treeRoot ;
  fhir:id [ fhir:v "rtpbc-claim-response-not-covered"] ; # 
  fhir:meta [
    ( fhir:profile [
fhir:v "http://hl7.org/fhir/us/carin-rtpbc/StructureDefinition/rtpbc-response-claimresponse"^^xsd:anyURI ;
fhir:link <http://hl7.org/fhir/us/carin-rtpbc/StructureDefinition/rtpbc-response-claimresponse>     ] )
  ] ; # 
  fhir:text [
fhir:status [ fhir:v "extensions" ] ;
fhir:div "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p class=\"res-header-id\"><b>Generated Narrative: ClaimResponse rtpbc-claim-response-not-covered</b></p><a name=\"rtpbc-claim-response-not-covered\"> </a><a name=\"hcrtpbc-claim-response-not-covered\"> </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-c-r</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: 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-not-covered\">RTPBC Benefit Restriction Code System not-covered</a>: Not covered</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 eligible}\">Eligible 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>0</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-prior-auth\">RTPBC Benefit Restriction Code System prior-auth</a>: Prior authorization required</p><p><b>RTPBC benefitRestriction Extension</b>: <a href=\"CodeSystem-rtpbc-benefit-restriction.html#rtpbc-benefit-restriction-quantity-limit\">RTPBC Benefit Restriction Code System quantity-limit</a>: Quantity limit applies</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 1734642}\">Zepatier 50 MG / 100 MG Oral Tablet</span></p><p><b>quantity</b>: 28 {Each}</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 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>405</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>469</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>874</td><td>United States dollar</td></tr></table></blockquote></blockquote><h3>ProcessNotes</h3><table class=\"grid\"><tr><td style=\"display: none\">-</td><td><b>Number</b></td><td><b>Text</b></td></tr><tr><td style=\"display: none\">*</td><td>1</td><td>Quantity limit: 28 tablets per month</td></tr></table></div>"^^rdf:XMLLiteral
  ] ; # 
  fhir:identifier ( [
fhir:value [ fhir:v "rtpbc-03-response-c-r" ]
  ] ) ; # 
  fhir:status [ fhir:v "active"] ; # 
  fhir:type [
    ( fhir:coding [
fhir:system [ fhir:v "http://terminology.hl7.org/CodeSystem/claim-type"^^xsd:anyURI ] ;
fhir:code [ fhir:v "pharmacy" ] ;
fhir:display [ fhir:v "Pharmacy" ]     ] )
  ] ; # 
  fhir:use [ fhir:v "predetermination"] ; # 
  fhir:patient [
fhir:reference [ fhir:v "Patient/rtpbc-patient-03" ]
  ] ; # 
  fhir:created [ fhir:v "2019-11-01T11:20:59-05:00"^^xsd:dateTime] ; # 
  fhir:insurer [
fhir:identifier [
fhir:value [ fhir:v "Pharmacy Plans US" ]     ]
  ] ; # 
  fhir:request [
fhir:identifier [
fhir:value [ fhir:v "rtpbc-03" ]     ]
  ] ; # 
  fhir:outcome [ fhir:v "complete"] ; # 
  fhir:disposition [ fhir:v "Processed successfully"] ; # 
  fhir:item ( [
    ( fhir:extension [
fhir:url [ fhir:v "http://hl7.org/fhir/us/carin-rtpbc/StructureDefinition/rtpbc-benefitRestriction"^^xsd:anyURI ] ;
fhir:value [
a fhir:Coding ;
fhir:system [ fhir:v "http://hl7.org/fhir/us/carin-rtpbc/CodeSystem/rtpbc-benefit-restriction"^^xsd:anyURI ] ;
fhir:code [ fhir:v "not-covered" ] ;
fhir:display [ fhir:v "Not covered" ]       ]     ] ) ;
fhir:itemSequence [ fhir:v "1"^^xsd:positiveInteger ] ;
    ( fhir:adjudication [
fhir:category [
        ( fhir:coding [
fhir:system [ fhir:v "http://hl7.org/fhir/us/carin-rtpbc/CodeSystem/rtpbc-patient-pay-type"^^xsd:anyURI ] ;
fhir:code [ fhir:v "eligible" ] ;
fhir:display [ fhir:v "Eligible amount" ]         ] )       ] ;
fhir:amount [
fhir:value [ fhir:v "0"^^xsd:decimal ] ;
fhir:currency [ fhir:v "USD" ]       ]     ] )
  ] ) ; # 
  fhir:addItem ( [
    ( fhir:extension [
fhir:url [ fhir:v "http://hl7.org/fhir/us/carin-rtpbc/StructureDefinition/rtpbc-isAlternative"^^xsd:anyURI ] ;
fhir:value [
a fhir:boolean ;
fhir:v true       ]     ] [
fhir:url [ fhir:v "http://hl7.org/fhir/us/carin-rtpbc/StructureDefinition/rtpbc-benefitRestriction"^^xsd:anyURI ] ;
fhir:value [
a fhir:Coding ;
fhir:system [ fhir:v "http://hl7.org/fhir/us/carin-rtpbc/CodeSystem/rtpbc-benefit-restriction"^^xsd:anyURI ] ;
fhir:code [ fhir:v "prior-auth" ] ;
fhir:display [ fhir:v "Prior authorization required" ]       ]     ] [
fhir:url [ fhir:v "http://hl7.org/fhir/us/carin-rtpbc/StructureDefinition/rtpbc-benefitRestriction"^^xsd:anyURI ] ;
fhir:value [
a fhir:Coding ;
fhir:system [ fhir:v "http://hl7.org/fhir/us/carin-rtpbc/CodeSystem/rtpbc-benefit-restriction"^^xsd:anyURI ] ;
fhir:code [ fhir:v "quantity-limit" ] ;
fhir:display [ fhir:v "Quantity limit applies" ]       ]     ] ) ;
    ( fhir:itemSequence [ fhir:v "1"^^xsd:positiveInteger ] ) ;
    ( fhir:provider [
fhir:reference [ fhir:v "Organization/rtpbc-organization-03wh" ]     ] ) ;
fhir:productOrService [
      ( fhir:coding [
fhir:system [ fhir:v "http://www.nlm.nih.gov/research/umls/rxnorm"^^xsd:anyURI ] ;
fhir:code [ fhir:v "1734642" ] ;
fhir:display [ fhir:v "Zepatier 50 MG / 100 MG Oral Tablet" ]       ] )     ] ;
fhir:quantity [
fhir:value [ fhir:v "28"^^xsd:decimal ] ;
fhir:unit [ fhir:v "{Each}" ]     ] ;
    ( fhir:noteNumber [ fhir:v "1"^^xsd:positiveInteger ] ) ;
    ( fhir:adjudication [
fhir:category [
        ( fhir:coding [
fhir:system [ fhir:v "http://hl7.org/fhir/us/carin-rtpbc/CodeSystem/rtpbc-patient-pay-type"^^xsd:anyURI ] ;
fhir:code [ fhir:v "copay" ] ;
fhir:display [ fhir:v "Copay" ]         ] )       ] ;
fhir:amount [
fhir:value [ fhir:v "405"^^xsd:decimal ] ;
fhir:currency [ fhir:v "USD" ]       ]     ] [
fhir:category [
        ( fhir:coding [
fhir:system [ fhir:v "http://hl7.org/fhir/us/carin-rtpbc/CodeSystem/rtpbc-patient-pay-type"^^xsd:anyURI ] ;
fhir:code [ fhir:v "coinsurance" ] ;
fhir:display [ fhir:v "Per prescription coinsurance" ]         ] )       ] ;
fhir:amount [
fhir:value [ fhir:v "469"^^xsd:decimal ] ;
fhir:currency [ fhir:v "USD" ]       ]     ] [
fhir:category [
        ( fhir:coding [
fhir:system [ fhir:v "http://hl7.org/fhir/us/carin-rtpbc/CodeSystem/rtpbc-patient-pay-type"^^xsd:anyURI ] ;
fhir:code [ fhir:v "total" ] ;
fhir:display [ fhir:v "Total patient responsibility" ]         ] )       ] ;
fhir:amount [
fhir:value [ fhir:v "874"^^xsd:decimal ] ;
fhir:currency [ fhir:v "USD" ]       ]     ] )
  ] ) ; # 
  fhir:processNote ( [
fhir:number [ fhir:v "1"^^xsd:positiveInteger ] ;
fhir:text [ fhir:v "Quantity limit: 28 tablets per month" ]
  ] ) . #