# rtpbc-claim-response-price-source - Consumer Real-Time Pharmacy Benefit Check FHIR IG v2.0.0-ballot

## Example ClaimResponse: rtpbc-claim-response-price-source

Language: en

Profile: [RTPBC Non-PHI Response Using ClaimResponse](StructureDefinition-rtpbc-response-claimresponse-non-phi.md)

**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

| | | |
| :--- | :--- | :--- |
| - | **Value** | **Currency** |
| * | 105 | United States dollar |


> **adjudication****category**: Coupon discount amount

### Amounts

| | | |
| :--- | :--- | :--- |
| - | **Value** | **Currency** |
| * | -20 | United States dollar |


> **adjudication****category**: Total patient responsibility

### Amounts

| | | |
| :--- | :--- | :--- |
| - | **Value** | **Currency** |
| * | 85 | United 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

| | | |
| :--- | :--- | :--- |
| - | **Value** | **Currency** |
| * | 50 | United States dollar |


> **adjudication****category**: Coupon discount amount

### Amounts

| | | |
| :--- | :--- | :--- |
| - | **Value** | **Currency** |
| * | -10 | United States dollar |


> **adjudication****category**: Total patient responsibility

### Amounts

| | | |
| :--- | :--- | :--- |
| - | **Value** | **Currency** |
| * | 40 | United States dollar |





## Resource Content

```json
{
  "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",
  "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"
      }
    }]
  }]
}

```
