{
  "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" : "<div xmlns=\"http://www.w3.org/1999/xhtml\" xml:lang=\"en\" lang=\"en\"><p class=\"res-header-id\"><b>Generated Narrative: ClaimResponse rtpbc-claim-response-price-source</b></p><a name=\"rtpbc-claim-response-price-source\"> </a><a name=\"hcrtpbc-claim-response-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\">Language: en</p><p style=\"margin-bottom: 0px\">Profile: <a href=\"StructureDefinition-rtpbc-response-claimresponse-non-phi.html\">RTPBC Non-PHI Response Using ClaimResponse</a></p></div><p><b>identifier</b>: rtpbc-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>: ?rref?</p><p><b>created</b>: 2025-11-15 13:10:13-0500</p><p><b>insurer</b>: ?rref?</p><p><b>request</b>: Identifier: rtpbc-01</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-temporary 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-temporary 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-temporary 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>productOrService</b>: <span title=\"Codes:{http://www.nlm.nih.gov/research/umls/rxnorm 205535}\">fluoxetine 10 MG Oral Capsule [Prozac]</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-temporary 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-temporary 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-temporary 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>"
  },
  "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"
      }
    }]
  }]
}