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 - XML Representation

Page standards status: Informative

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<ClaimResponse xmlns="http://hl7.org/fhir">
  <id value="rtpbc-claim-response-not-covered"/>
  <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-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>
  </text>
  <identifier>
    <value value="rtpbc-03-response-c-r"/>
  </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-03"/>
  </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="not-covered"/>
        <display value="Not covered"/>
      </valueCoding>
    </extension>
    <itemSequence value="1"/>
    <adjudication>
      <category>
        <coding>
          <system
                  value="http://hl7.org/fhir/us/carin-rtpbc/CodeSystem/rtpbc-patient-pay-type"/>
          <code value="eligible"/>
          <display value="Eligible amount"/>
        </coding>
      </category>
      <amount>
        <value value="0"/>
        <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="prior-auth"/>
        <display value="Prior authorization required"/>
      </valueCoding>
    </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="quantity-limit"/>
        <display value="Quantity limit applies"/>
      </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="1734642"/>
        <display value="Zepatier 50 MG / 100 MG Oral Tablet"/>
      </coding>
    </productOrService>
    <quantity>
      <value value="28"/>
      <unit value="{Each}"/>
    </quantity>
    <noteNumber 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="405"/>
        <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="469"/>
        <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="874"/>
        <currency value="USD"/>
      </amount>
    </adjudication>
  </addItem>
  <processNote>
    <number value="1"/>
    <text value="Quantity limit: 28 tablets per month"/>
  </processNote>
</ClaimResponse>