This resource provides the adjudication details from the processing of a Claim resource.

Unique ClaimResponse Resource Identifier assigned by the responding payer/PBM

The only time that a resource does not have an id is when it is being submitted to the server using a create operation.

A reference to a set of rules that were followed when the resource was constructed, and which must be understood when processing the content. Often, this is a reference to an implementation guide that defines the special rules along with other profiles etc.

Asserting this rule set restricts the content to be only understood by a limited set of trading partners. This inherently limits the usefulness of the data in the long term. However, the existing health eco-system is highly fractured, and not yet ready to define, collect, and exchange data in a generally computable sense. Wherever possible, implementers and/or specification writers should avoid using this element. Often, when used, the URL is a reference to an implementation guide that defines these special rules as part of it's narrative along with other profiles, value sets, etc.

May be used to represent additional information that is not part of the basic definition of the resource and that modifies the understanding of the element that contains it and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

A unique identifier assigned to this claim response.

Allows claim responses to be distinguished and referenced.

The purpose of this identifier.

Applications can assume that an identifier is permanent unless it explicitly says that it is temporary.

Identifies the purpose for this identifier, if known .

Allows the appropriate identifier for a particular context of use to be selected from among a set of identifiers.

An identifier for each RTPBC response that is assigned by and unique to the reponder

If the value is a full URI, then the system SHALL be urn:ietf:rfc:3986. The value's primary purpose is computational mapping. As a result, it may be normalized for comparison purposes (e.g. removing non-significant whitespace, dashes, etc.) A value formatted for human display can be conveyed using the Rendered Value extension. Identifier.value is to be treated as case sensitive unless knowledge of the Identifier.system allows the processer to be confident that non-case-sensitive processing is safe.

The status of this response (active)

Value is always 'active'

A code specifying the state of the resource instance.

Need to track the status of the resource as 'draft' resources may undergo further edits while 'active' resources are immutable and may only have their status changed to 'cancelled'.

The type of service for which pricing and coverage predetermination is being requested

Value is always 'pharmacy'

The type or discipline-style of the claim.

Some jurisdictions need a finer grained claim type for routing and adjudication.

A reference to a code defined by a terminology system.

Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labeled as UserSelected = true.

Allows for alternative encodings within a code system, and translations to other code systems.

The identification of the code system that defines the meaning of the symbol in the code.

The URI may be an OID (urn:oid:...) or a UUID (urn:uuid:...). OIDs and UUIDs SHALL be references to the HL7 OID registry. Otherwise, the URI should come from HL7's list of FHIR defined special URIs or it should reference to some definition that establishes the system clearly and unambiguously.

Need to be unambiguous about the source of the definition of the symbol.

A symbol in syntax defined by the system. The symbol may be a predefined code or an expression in a syntax defined by the coding system (e.g. post-coordination).

Need to refer to a particular code in the system.

A representation of the meaning of the code in the system, following the rules of the system.

Need to be able to carry a human-readable meaning of the code for readers that do not know the system.

The mode of processing being performed by the payer/PBM

Value is always 'predetermination'

Claim, preauthorization, predetermination.

This element is required to understand the nature of the request for adjudication.

Limited patient information required in the consumer real-time pharmacy benefit check (RTPBC) process

Echo the Patient resource received in the request

The patient must be supplied to the insurer so that confirmation of coverage and service hstory may be considered as part of the authorization and/or adjudiction.

The date this resource was created.

Need to record a timestamp for use by both the recipient and the issuer.

The party responsible for authorization, adjudication and reimbursement.

To be a valid claim, preauthorization or predetermination there must be a party who is responsible for adjudicating the contents against a policy which provides benefits for the patient.

An identifier for the target resource. This is used when there is no way to reference the other resource directly, either because the entity it represents is not available through a FHIR server, or because there is no way for the author of the resource to convert a known identifier to an actual location. There is no requirement that a Reference.identifier point to something that is actually exposed as a FHIR instance, but it SHALL point to a business concept that would be expected to be exposed as a FHIR instance, and that instance would need to be of a FHIR resource type allowed by the reference.

When an identifier is provided in place of a reference, any system processing the reference will only be able to resolve the identifier to a reference if it understands the business context in which the identifier is used. Sometimes this is global (e.g. a national identifier) but often it is not. For this reason, none of the useful mechanisms described for working with references (e.g. chaining, includes) are possible, nor should servers be expected to be able resolve the reference. Servers may accept an identifier based reference untouched, resolve it, and/or reject it - see CapabilityStatement.rest.resource.referencePolicy.

When both an identifier and a literal reference are provided, the literal reference is preferred. Applications processing the resource are allowed - but not required - to check that the identifier matches the literal reference

Applications converting a logical reference to a literal reference may choose to leave the logical reference present, or remove it.

Reference is intended to point to a structure that can potentially be expressed as a FHIR resource, though there is no need for it to exist as an actual FHIR resource instance - except in as much as an application wishes to actual find the target of the reference. The content referred to be the identifier must meet the logical constraints implied by any limitations on what resource types are permitted for the reference. For example, it would not be legitimate to send the identifier for a drug prescription if the type were Reference(Observation|DiagnosticReport). One of the use-cases for Reference.identifier is the situation where no FHIR representation exists (where the type is Reference (Any).

The purpose of this identifier.

Applications can assume that an identifier is permanent unless it explicitly says that it is temporary.

Identifies the purpose for this identifier, if known .

Allows the appropriate identifier for a particular context of use to be selected from among a set of identifiers.

The portion of the identifier typically relevant to the user and which is unique within the context of the system.

If the value is a full URI, then the system SHALL be urn:ietf:rfc:3986. The value's primary purpose is computational mapping. As a result, it may be normalized for comparison purposes (e.g. removing non-significant whitespace, dashes, etc.) A value formatted for human display can be conveyed using the Rendered Value extension. Identifier.value is to be treated as case sensitive unless knowledge of the Identifier.system allows the processer to be confident that non-case-sensitive processing is safe.

The RTPBC Request ID contained in the associated request

An identifier for the target resource. This is used when there is no way to reference the other resource directly, either because the entity it represents is not available through a FHIR server, or because there is no way for the author of the resource to convert a known identifier to an actual location. There is no requirement that a Reference.identifier point to something that is actually exposed as a FHIR instance, but it SHALL point to a business concept that would be expected to be exposed as a FHIR instance, and that instance would need to be of a FHIR resource type allowed by the reference.

When an identifier is provided in place of a reference, any system processing the reference will only be able to resolve the identifier to a reference if it understands the business context in which the identifier is used. Sometimes this is global (e.g. a national identifier) but often it is not. For this reason, none of the useful mechanisms described for working with references (e.g. chaining, includes) are possible, nor should servers be expected to be able resolve the reference. Servers may accept an identifier based reference untouched, resolve it, and/or reject it - see CapabilityStatement.rest.resource.referencePolicy.

When both an identifier and a literal reference are provided, the literal reference is preferred. Applications processing the resource are allowed - but not required - to check that the identifier matches the literal reference

Applications converting a logical reference to a literal reference may choose to leave the logical reference present, or remove it.

Reference is intended to point to a structure that can potentially be expressed as a FHIR resource, though there is no need for it to exist as an actual FHIR resource instance - except in as much as an application wishes to actual find the target of the reference. The content referred to be the identifier must meet the logical constraints implied by any limitations on what resource types are permitted for the reference. For example, it would not be legitimate to send the identifier for a drug prescription if the type were Reference(Observation|DiagnosticReport). One of the use-cases for Reference.identifier is the situation where no FHIR representation exists (where the type is Reference (Any).

The purpose of this identifier.

Applications can assume that an identifier is permanent unless it explicitly says that it is temporary.

Identifies the purpose for this identifier, if known .

Allows the appropriate identifier for a particular context of use to be selected from among a set of identifiers.

The RTPBC Request ID contained in the associated request

Populate with the Claim.identifier.value from the associated request

The outcome of processing. Either 'complete' (finished without errors) or 'error' (processing could not complete). The outcome is 'processed' if processing completes with a coverage determination, including when it is determined that the requested product is not covered. Otherwise, the outcome = 'error'.

Note: If a system or communication error occurs, an OperationOutcome is returned instead of a ClaimResponse

If the outcome = 'error', the .error composite must be populated.

The result of the claim processing.

To advise the requestor of an overall processing outcome.

Note providing clarifying information and/or support contact information. Available for both 'completed' and 'error' outcomes.

The responding payer/PBM determines when and how to populate.Recommended that a patient help desk phone number be included.

Corresponds to the Help Desk Support elements in the NCPDP RTPBC response message.

Composite containing cost and coverage for the requested product and pharmacy.

SHALL be populated when the .outcome = 'complete'.

The adjudication for items provided on the claim.

An Extension

This extension conveys benefit restrictions that may apply to a prescription product and pharmacy combination.

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

Indicates that the information in this .item composite relates to the requested product and pharmacy.

Necessary to provide a mechanism to link the adjudication result to the submitted claim item.

Number referencing a Determination Note (.processNote) explaining the coverage status for this product + pharmacy combination.

Provides a condensed manner for associating human readable descriptive explanations for adjudications on the line item.

Patient cost and coverage details for the requested product and pharmacy.

The adjudication results conveys the insurer's assessment of the item provided in the claim under the terms of the patient's insurance coverage.

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

Identifies a component of the patient's financial responsibility for the product cost.

At least one .adjudication must contain a .category with the .code value 'total', representing the patient's total financial responsibility for the product

RTPBC Patient Pay Categories

Corresponds to NCPDP C95-KQ Patient Pay Component Qualifier.

The amount associated with the Patient Pay Component (.adjudication.category).

For example: amount submitted, eligible amount, co-payment, and benefit payable.

Most adjuciation categories convey a monetary amount.

The patient pay component amount in terms of the specified currency.

Monetary values have their own rules for handling precision (refer to standard accounting text books).

The amount of the currency. The value includes an implicit precision in the presentation of the value.

ISO 4217 Currency Code.

Currencies

A code indicating the currency, taken from ISO 4217.

The first-tier service adjudications for payor added product or service lines.

Insurers may redefine the provided product or service or may package and/or decompose groups of products and services. The addItems allows the insurer to provide their line item list with linkage to the submitted items/details/sub-details. In a preauthorization the insurer may use the addItem structure to provide additional information on authorized products and services.

An Extension

This extension indicates that this added line item is to be interpreted as one of possibly multiple alternatives to the requested product or service. When isAlternative is true, the added line item is to be considered independently from any other added line items associated with the requested product or service

Set to true in all real-time pharmacy benefit check response .addItems.

This extension conveys benefit restrictions that may apply to a prescription product and pharmacy combination.

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

Indicates that the information in this .item composite is an alternative to the requested product and pharmacy.

Because a maximum of one product is submitted per request, this value is always '1'.

Provides references to the claim items.

Reference to an Organization resource representing the priced pharmacy

Insurer may provide authorization specifically to a restricted set of providers rather than an open authorization.

A reference to a location at which the other resource is found. The reference may be a relative reference, in which case it is relative to the service base URL, or an absolute URL that resolves to the location where the resource is found. The reference may be version specific or not. If the reference is not to a FHIR RESTful server, then it should be assumed to be version specific. Internal fragment references (start with '#') refer to contained resources.

Using absolute URLs provides a stable scalable approach suitable for a cloud/web context, while using relative/logical references provides a flexible approach suitable for use when trading across closed eco-system boundaries. Absolute URLs do not need to point to a FHIR RESTful server, though this is the preferred approach. If the URL conforms to the structure "/[type]/[id]" then it should be assumed that the reference is to a FHIR RESTful server.

A product identifier for the medication. Either an NDC11 or an RxNorm code for a prescribable product (representing drug name, strength and dose form)

The NDC11 is an 11-digit normalized format consisting of a 5-digit labeler segment, 4-digit product segment, and 2-digit package segment, with no dashes

RTPBC prescribable product codes (NDC11 and RxNorm)

Necessary to state what was provided or done.

A reference to a code defined by a terminology system.

Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labeled as UserSelected = true.

Allows for alternative encodings within a code system, and translations to other code systems.

The identification of the code system that defines the meaning of the symbol in the code.

The URI may be an OID (urn:oid:...) or a UUID (urn:uuid:...). OIDs and UUIDs SHALL be references to the HL7 OID registry. Otherwise, the URI should come from HL7's list of FHIR defined special URIs or it should reference to some definition that establishes the system clearly and unambiguously.

Need to be unambiguous about the source of the definition of the symbol.

A symbol in syntax defined by the system. The symbol may be a predefined code or an expression in a syntax defined by the coding system (e.g. post-coordination).

Need to refer to a particular code in the system.

The full prescribable product name, including drug name, strength and dose form. The drug name equals the brand name if the branded product is desired.

Need to be able to carry a human-readable meaning of the code for readers that do not know the system.

The number of repetitions of a service or product.

Required when the product or service code does not convey the quantity provided.

The prescribed quantity in terms of the applicable billing unit of measure.

The implicit precision in the value should always be honored. Monetary values have their own rules for handling precision (refer to standard accounting text books).

Precision is handled implicitly in almost all cases of measurement.

Not allowed to be used in this context

How the Quantity should be understood and represented.

Need a framework for handling measures where the value is <5ug/L or >400mg/L due to the limitations of measuring methodology.

Pharmacy metric billing unit: GM (gram), ML (milliliter) or EA (each)

Billing quantity unit of measure

There are many representations for units of measure and in many contexts, particular representations are fixed and required. I.e. mcg for micrograms.

Number referencing a Determination Note (.processNote) explaining the coverage status for this product + pharmacy combination.

Provides a condensed manner for associating human readable descriptive explanations for adjudications on the line item.

Patient cost and coverage details for an alternative product and pharmacy combination.

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

Identifies a component of the patient's financial responsibility for the product cost.

At least one .adjudication must contain a .category with the .code value 'total', representing the patient's total financial responsibility for the product

RTPBC Patient Pay Categories

Corresponds to NCPDP C95-KQ Patient Pay Component Qualifier.

The amount associated with the Patient Pay Component (.adjudication.category).

For example: amount submitted, eligible amount, co-payment, and benefit payable.

Most adjuciation categories convey a monetary amount.

The patient pay component amount in terms of the specified currency.

Monetary values have their own rules for handling precision (refer to standard accounting text books).

The amount of the currency. The value includes an implicit precision in the presentation of the value.

ISO 4217 Currency Code.

Currencies

A code indicating the currency, taken from ISO 4217.

Additional coverage determination information for a product / pharmacy combination.

Provides the insurer specific textual explanations associated with the processing.

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

A number to uniquely identify a note entry.

Links to the .noteNumber elements in .item and .addItem

Necessary to provide a mechanism to link from adjudications.

The explanation or description associated with the processing.

Required to provide human readable explanation.

Errors encountered during the processing of the adjudication.

Must be populated when .outcome = 'error'

Need to communicate processing issues to the requestor.

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

A code identifying the reason that processing could not be completed.

RTPBC Error Codes

Required to convey processing errors.

A reference to a code defined by a terminology system.

Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labeled as UserSelected = true.

Allows for alternative encodings within a code system, and translations to other code systems.

The identification of the code system that defines the meaning of the symbol in the code.

The URI may be an OID (urn:oid:...) or a UUID (urn:uuid:...). OIDs and UUIDs SHALL be references to the HL7 OID registry. Otherwise, the URI should come from HL7's list of FHIR defined special URIs or it should reference to some definition that establishes the system clearly and unambiguously.

Need to be unambiguous about the source of the definition of the symbol.

A symbol in syntax defined by the system. The symbol may be a predefined code or an expression in a syntax defined by the coding system (e.g. post-coordination).

Need to refer to a particular code in the system.

A representation of the meaning of the code in the system, following the rules of the system.

Need to be able to carry a human-readable meaning of the code for readers that do not know the system.

Clarification of the reject cause.

Very often the text is the same as a displayName of one of the codings.

The codes from the terminologies do not always capture the correct meaning with all the nuances of the human using them, or sometimes there is no appropriate code at all. In these cases, the text is used to capture the full meaning of the source.

Unique ClaimResponse Resource Identifier assigned by the responding payer/PBM

An identifier for each RTPBC response that is assigned by and unique to the reponder

The status of this response (active)

Value is always 'active'

The type of service for which pricing and coverage predetermination is being requested

Value is always 'pharmacy'

The mode of processing being performed by the payer/PBM

Value is always 'predetermination'

Limited patient information required in the consumer real-time pharmacy benefit check (RTPBC) process

Echo the Patient resource received in the request

The RTPBC Request ID contained in the associated request

The RTPBC Request ID contained in the associated request

Populate with the Claim.identifier.value from the associated request

The outcome of processing. Either 'complete' (finished without errors) or 'error' (processing could not complete). The outcome is 'processed' if processing completes with a coverage determination, including when it is determined that the requested product is not covered. Otherwise, the outcome = 'error'.

Note: If a system or communication error occurs, an OperationOutcome is returned instead of a ClaimResponse

If the outcome = 'error', the .error composite must be populated.

Note providing clarifying information and/or support contact information. Available for both 'completed' and 'error' outcomes.

The responding payer/PBM determines when and how to populate.Recommended that a patient help desk phone number be included.

Corresponds to the Help Desk Support elements in the NCPDP RTPBC response message.

Composite containing cost and coverage for the requested product and pharmacy.

SHALL be populated when the .outcome = 'complete'.

This extension conveys benefit restrictions that may apply to a prescription product and pharmacy combination.

Indicates that the information in this .item composite relates to the requested product and pharmacy.

Number referencing a Determination Note (.processNote) explaining the coverage status for this product + pharmacy combination.

Patient cost and coverage details for the requested product and pharmacy.

Identifies a component of the patient's financial responsibility for the product cost.

At least one .adjudication must contain a .category with the .code value 'total', representing the patient's total financial responsibility for the product

RTPBC Patient Pay Categories

Corresponds to NCPDP C95-KQ Patient Pay Component Qualifier.

The amount associated with the Patient Pay Component (.adjudication.category).

The patient pay component amount in terms of the specified currency.

Currencies

This extension indicates that this added line item is to be interpreted as one of possibly multiple alternatives to the requested product or service. When isAlternative is true, the added line item is to be considered independently from any other added line items associated with the requested product or service

Set to true in all real-time pharmacy benefit check response .addItems.

This extension conveys benefit restrictions that may apply to a prescription product and pharmacy combination.

Indicates that the information in this .item composite is an alternative to the requested product and pharmacy.

Because a maximum of one product is submitted per request, this value is always '1'.

Reference to an Organization resource representing the priced pharmacy

A product identifier for the medication. Either an NDC11 or an RxNorm code for a prescribable product (representing drug name, strength and dose form)

The NDC11 is an 11-digit normalized format consisting of a 5-digit labeler segment, 4-digit product segment, and 2-digit package segment, with no dashes

RTPBC prescribable product codes (NDC11 and RxNorm)

The full prescribable product name, including drug name, strength and dose form. The drug name equals the brand name if the branded product is desired.

The prescribed quantity in terms of the applicable billing unit of measure.

Pharmacy metric billing unit: GM (gram), ML (milliliter) or EA (each)

Billing quantity unit of measure

Number referencing a Determination Note (.processNote) explaining the coverage status for this product + pharmacy combination.

Patient cost and coverage details for an alternative product and pharmacy combination.

Identifies a component of the patient's financial responsibility for the product cost.

At least one .adjudication must contain a .category with the .code value 'total', representing the patient's total financial responsibility for the product

RTPBC Patient Pay Categories

Corresponds to NCPDP C95-KQ Patient Pay Component Qualifier.

The amount associated with the Patient Pay Component (.adjudication.category).

The patient pay component amount in terms of the specified currency.

Currencies

Additional coverage determination information for a product / pharmacy combination.

Links to the .noteNumber elements in .item and .addItem

Must be populated when .outcome = 'error'

A code identifying the reason that processing could not be completed.

RTPBC Error Codes

Clarification of the reject cause.

This resource provides the adjudication details from the processing of a Claim resource.

Unique ClaimResponse Resource Identifier assigned by the responding payer/PBM

The only time that a resource does not have an id is when it is being submitted to the server using a create operation.

The metadata about the resource. This is content that is maintained by the infrastructure. Changes to the content might not always be associated with version changes to the resource.

A reference to a set of rules that were followed when the resource was constructed, and which must be understood when processing the content. Often, this is a reference to an implementation guide that defines the special rules along with other profiles etc.

Asserting this rule set restricts the content to be only understood by a limited set of trading partners. This inherently limits the usefulness of the data in the long term. However, the existing health eco-system is highly fractured, and not yet ready to define, collect, and exchange data in a generally computable sense. Wherever possible, implementers and/or specification writers should avoid using this element. Often, when used, the URL is a reference to an implementation guide that defines these special rules as part of it's narrative along with other profiles, value sets, etc.

The base language in which the resource is written.

Language is provided to support indexing and accessibility (typically, services such as text to speech use the language tag). The html language tag in the narrative applies to the narrative. The language tag on the resource may be used to specify the language of other presentations generated from the data in the resource. Not all the content has to be in the base language. The Resource.language should not be assumed to apply to the narrative automatically. If a language is specified, it should it also be specified on the div element in the html (see rules in HTML5 for information about the relationship between xml:lang and the html lang attribute).

A human language.

A human-readable narrative that contains a summary of the resource and can be used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative. Resource definitions may define what content should be represented in the narrative to ensure clinical safety.

Contained resources do not have narrative. Resources that are not contained SHOULD have a narrative. In some cases, a resource may only have text with little or no additional discrete data (as long as all minOccurs=1 elements are satisfied). This may be necessary for data from legacy systems where information is captured as a "text blob" or where text is additionally entered raw or narrated and encoded information is added later.

These resources do not have an independent existence apart from the resource that contains them - they cannot be identified independently, and nor can they have their own independent transaction scope.

This should never be done when the content can be identified properly, as once identification is lost, it is extremely difficult (and context dependent) to restore it again. Contained resources may have profiles and tags In their meta elements, but SHALL NOT have security labels.

May be used to represent additional information that is not part of the basic definition of the resource. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

May be used to represent additional information that is not part of the basic definition of the resource and that modifies the understanding of the element that contains it and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

A unique identifier assigned to this claim response.

Allows claim responses to be distinguished and referenced.

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

The purpose of this identifier.

Applications can assume that an identifier is permanent unless it explicitly says that it is temporary.

Identifies the purpose for this identifier, if known .

Allows the appropriate identifier for a particular context of use to be selected from among a set of identifiers.

A coded type for the identifier that can be used to determine which identifier to use for a specific purpose.

This element deals only with general categories of identifiers. It SHOULD not be used for codes that correspond 1..1 with the Identifier.system. Some identifiers may fall into multiple categories due to common usage. Where the system is known, a type is unnecessary because the type is always part of the system definition. However systems often need to handle identifiers where the system is not known. There is not a 1:1 relationship between type and system, since many different systems have the same type.

A coded type for an identifier that can be used to determine which identifier to use for a specific purpose.

Allows users to make use of identifiers when the identifier system is not known.

Establishes the namespace for the value - that is, a URL that describes a set values that are unique.

Identifier.system is always case sensitive.

There are many sets of identifiers. To perform matching of two identifiers, we need to know what set we're dealing with. The system identifies a particular set of unique identifiers.

An identifier for each RTPBC response that is assigned by and unique to the reponder

If the value is a full URI, then the system SHALL be urn:ietf:rfc:3986. The value's primary purpose is computational mapping. As a result, it may be normalized for comparison purposes (e.g. removing non-significant whitespace, dashes, etc.) A value formatted for human display can be conveyed using the Rendered Value extension. Identifier.value is to be treated as case sensitive unless knowledge of the Identifier.system allows the processer to be confident that non-case-sensitive processing is safe.

Time period during which identifier is/was valid for use.

Organization that issued/manages the identifier.

The Identifier.assigner may omit the .reference element and only contain a .display element reflecting the name or other textual information about the assigning organization.

The status of this response (active)

Value is always 'active'

A code specifying the state of the resource instance.

Need to track the status of the resource as 'draft' resources may undergo further edits while 'active' resources are immutable and may only have their status changed to 'cancelled'.

The type of service for which pricing and coverage predetermination is being requested

Value is always 'pharmacy'

The type or discipline-style of the claim.

Some jurisdictions need a finer grained claim type for routing and adjudication.

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

A reference to a code defined by a terminology system.

Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labeled as UserSelected = true.

Allows for alternative encodings within a code system, and translations to other code systems.

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

The identification of the code system that defines the meaning of the symbol in the code.

The URI may be an OID (urn:oid:...) or a UUID (urn:uuid:...). OIDs and UUIDs SHALL be references to the HL7 OID registry. Otherwise, the URI should come from HL7's list of FHIR defined special URIs or it should reference to some definition that establishes the system clearly and unambiguously.

Need to be unambiguous about the source of the definition of the symbol.

The version of the code system which was used when choosing this code. Note that a well-maintained code system does not need the version reported, because the meaning of codes is consistent across versions. However this cannot consistently be assured, and when the meaning is not guaranteed to be consistent, the version SHOULD be exchanged.

Where the terminology does not clearly define what string should be used to identify code system versions, the recommendation is to use the date (expressed in FHIR date format) on which that version was officially published as the version date.

A symbol in syntax defined by the system. The symbol may be a predefined code or an expression in a syntax defined by the coding system (e.g. post-coordination).

Need to refer to a particular code in the system.

A representation of the meaning of the code in the system, following the rules of the system.

Need to be able to carry a human-readable meaning of the code for readers that do not know the system.

Indicates that this coding was chosen by a user directly - e.g. off a pick list of available items (codes or displays).

Amongst a set of alternatives, a directly chosen code is the most appropriate starting point for new translations. There is some ambiguity about what exactly 'directly chosen' implies, and trading partner agreement may be needed to clarify the use of this element and its consequences more completely.

This has been identified as a clinical safety criterium - that this exact system/code pair was chosen explicitly, rather than inferred by the system based on some rules or language processing.

A human language representation of the concept as seen/selected/uttered by the user who entered the data and/or which represents the intended meaning of the user.

Very often the text is the same as a displayName of one of the codings.

The codes from the terminologies do not always capture the correct meaning with all the nuances of the human using them, or sometimes there is no appropriate code at all. In these cases, the text is used to capture the full meaning of the source.

A finer grained suite of claim type codes which may convey additional information such as Inpatient vs Outpatient and/or a specialty service.

This may contain the local bill type codes, for example the US UB-04 bill type code or the CMS bill type.

A more granular claim typecode.