{ "resourceType" : "Bundle", "id" : "rtpbc-bundle-response-price-source", "meta" : { "profile" : ["http://hl7.org/fhir/us/carin-rtpbc/StructureDefinition/rtpbc-response-bundle-non-phi"] }, "language" : "en", "type" : "message", "timestamp" : "2025-11-15T13:10:13-05:00", "entry" : [{ "fullUrl" : "http://example.org/my-app/MessageHeader/rtpbc-messageheader-response-price-source", "resource" : { "resourceType" : "MessageHeader", "id" : "rtpbc-messageheader-response-price-source", "meta" : { "profile" : ["http://hl7.org/fhir/us/carin-rtpbc/StructureDefinition/rtpbc-response-messageheader-non-phi"] }, "language" : "en", "text" : { "status" : "generated", "div" : "

Generated Narrative: MessageHeader rtpbc-messageheader-response-price-source

Profile: RTPBC Non-PHI Response MessageHeader

event: RTPBC Event Type Code System: rtpbc-response-non-phi (RTPBC Non-PHI Response)

Sources

-NameEndpoint
*GoodPricinghttp://example.org/GoodPricing/fhir

Responses

-IdentifierCode
*rtpbc-messageheader-request-non-phi-1OK

focus: ClaimResponse: identifier = rtpbc-response-price-source; status = active; type = Pharmacy; use = predetermination; created = 2025-11-15 13:10:13-0500; outcome = complete; disposition = Processed successfully

definition: RTPBC Non-PHI Response Message Definition

" }, "eventCoding" : { "system" : "http://hl7.org/fhir/us/carin-rtpbc/CodeSystem/rtpbc-event-type", "code" : "rtpbc-response-non-phi", "display" : "RTPBC Non-PHI Response" }, "source" : { "name" : "GoodPricing", "endpoint" : "http://example.org/GoodPricing/fhir" }, "response" : { "identifier" : "rtpbc-messageheader-request-non-phi-1", "code" : "ok" }, "focus" : [{ "reference" : "http://example.org/my-app/ClaimResponse/rtpbc-claim-response-price-source" }], "definition" : "http://hl7.org/fhir/us/carin-rtpbc/MessageDefinition/rtpbc-response-non-phi" } }, { "fullUrl" : "http://example.org/my-app/ClaimResponse/rtpbc-claim-response-price-source", "resource" : { "resourceType" : "ClaimResponse", "id" : "rtpbc-claim-response-price-source", "meta" : { "profile" : ["http://hl7.org/fhir/us/carin-rtpbc/StructureDefinition/rtpbc-response-claimresponse-non-phi"] }, "language" : "en", "text" : { "status" : "extensions", "div" : "

Generated Narrative: ClaimResponse rtpbc-claim-response-price-source

Profile: RTPBC Non-PHI Response Using ClaimResponse

identifier: rtpbc-response-price-source

status: Active

type: Pharmacy

use: Predetermination

patient: ?rref?

created: 2025-11-15 13:10:13-0500

insurer: ?rref?

request: Identifier: rtpbc-01

outcome: Processing Complete

disposition: Processed successfully

item

itemSequence: 1

noteNumber: 1

adjudication

category: Full product cash price

Amounts

-ValueCurrency
*105United States dollar

adjudication

category: Coupon discount amount

Amounts

-ValueCurrency
*-20United States dollar

adjudication

category: Total patient responsibility

Amounts

-ValueCurrency
*85United States dollar

addItem

RTPBC isAlternative Extension: true

itemSequence: 1

productOrService: fluoxetine 10 MG Oral Capsule [Prozac]

quantity: 60 {Each}

adjudication

category: Full product cash price

Amounts

-ValueCurrency
*50United States dollar

adjudication

category: Coupon discount amount

Amounts

-ValueCurrency
*-10United States dollar

adjudication

category: Total patient responsibility

Amounts

-ValueCurrency
*40United States dollar
" }, "identifier" : [{ "value" : "rtpbc-response-price-source" }], "status" : "active", "type" : { "coding" : [{ "system" : "http://terminology.hl7.org/CodeSystem/claim-type", "code" : "pharmacy", "display" : "Pharmacy" }] }, "use" : "predetermination", "patient" : { "extension" : [{ "url" : "http://hl7.org/fhir/StructureDefinition/data-absent-reason", "valueCode" : "masked" }] }, "created" : "2025-11-15T13:10:13-05:00", "insurer" : { "extension" : [{ "url" : "http://hl7.org/fhir/StructureDefinition/data-absent-reason", "valueCode" : "masked" }] }, "request" : { "identifier" : { "value" : "rtpbc-01" } }, "outcome" : "complete", "disposition" : "Processed successfully", "item" : [{ "itemSequence" : 1, "noteNumber" : [1], "adjudication" : [{ "category" : { "coding" : [{ "system" : "http://hl7.org/fhir/us/carin-rtpbc/CodeSystem/rtpbc-patient-pay-type-temporary", "code" : "cash-price", "display" : "Full product cash price" }] }, "amount" : { "value" : 105, "currency" : "USD" } }, { "category" : { "coding" : [{ "system" : "http://hl7.org/fhir/us/carin-rtpbc/CodeSystem/rtpbc-patient-pay-type-temporary", "code" : "coupon-discount", "display" : "Coupon discount amount" }] }, "amount" : { "value" : -20, "currency" : "USD" } }, { "category" : { "coding" : [{ "system" : "http://hl7.org/fhir/us/carin-rtpbc/CodeSystem/rtpbc-patient-pay-type-temporary", "code" : "total", "display" : "Total patient responsibility" }] }, "amount" : { "value" : 85, "currency" : "USD" } }] }], "addItem" : [{ "extension" : [{ "url" : "http://hl7.org/fhir/us/carin-rtpbc/StructureDefinition/rtpbc-isAlternative", "valueBoolean" : true }], "itemSequence" : [1], "productOrService" : { "coding" : [{ "system" : "http://www.nlm.nih.gov/research/umls/rxnorm", "code" : "205535", "display" : "fluoxetine 10 MG Oral Capsule [Prozac]" }] }, "quantity" : { "value" : 60, "unit" : "{Each}" }, "adjudication" : [{ "category" : { "coding" : [{ "system" : "http://hl7.org/fhir/us/carin-rtpbc/CodeSystem/rtpbc-patient-pay-type-temporary", "code" : "cash-price", "display" : "Full product cash price" }] }, "amount" : { "value" : 50, "currency" : "USD" } }, { "category" : { "coding" : [{ "system" : "http://hl7.org/fhir/us/carin-rtpbc/CodeSystem/rtpbc-patient-pay-type-temporary", "code" : "coupon-discount", "display" : "Coupon discount amount" }] }, "amount" : { "value" : -10, "currency" : "USD" } }, { "category" : { "coding" : [{ "system" : "http://hl7.org/fhir/us/carin-rtpbc/CodeSystem/rtpbc-patient-pay-type-temporary", "code" : "total", "display" : "Total patient responsibility" }] }, "amount" : { "value" : 40, "currency" : "USD" } }] }] } }] }