# rtpbc-claim-response-01 - Consumer Real-Time Pharmacy Benefit Check FHIR IG v2.0.0-ballot

## Example ClaimResponse: rtpbc-claim-response-01

Language: en

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

**identifier**: rtpbc-01-response

**status**: Active

**type**: Pharmacy

**use**: Predetermination

**patient**: [Jane Doe Female, DoB: 1975-12-05 ( Patient internal identifier: 30455)](Patient-rtpbc-patient-01.md)

**created**: 2025-12-11 11:20:59-0500

**insurer**: Identifier: Pharmacy Plans US

**request**: Identifier: rtpbc-01

**outcome**: Processing Complete

**disposition**: Processed successfully

> **item****RTPBC benefitRestriction Extension**: [RTPBC Benefit Restriction Code System (Temporary): prior-auth](CodeSystem-rtpbc-benefit-restriction-temporary.md#rtpbc-benefit-restriction-temporary-prior-auth) (Prior authorization required)**RTPBC formularyStatus Extension**: [NCPDP Formulary Status Code System (Temporary): O](CodeSystem-ncpdp-formulary-status-temporary.md#ncpdp-formulary-status-temporary-O) (On Formulary)**RTPBC preferenceLevel Extension**: 2**RTPBC nextAvailableFillDate Extension**: 2025-12-20**itemSequence**: 1
> **adjudication****category**: Copay

### Amounts

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


> **adjudication****category**: Per prescription coinsurance

### Amounts

| | | |
| :--- | :--- | :--- |
| - | **Value** | **Currency** |
| * | 30 | United States dollar |


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

### Amounts

| | | |
| :--- | :--- | :--- |
| - | **Value** | **Currency** |
| * | 70 | United States dollar |



> **addItem****RTPBC isAlternative Extension**: true**RTPBC benefitRestriction Extension**: [RTPBC Benefit Restriction Code System (Temporary): covered](CodeSystem-rtpbc-benefit-restriction-temporary.md#rtpbc-benefit-restriction-temporary-covered) (Covered)**RTPBC formularyStatus Extension**: [NCPDP Formulary Status Code System (Temporary): P](CodeSystem-ncpdp-formulary-status-temporary.md#ncpdp-formulary-status-temporary-P) (On Formulary/Preferred)**RTPBC preferenceLevel Extension**: 1**itemSequence**: 1**provider**: [Organization My Mail Service Pharmacy](Organization-rtpbc-organization-03m.md)**productOrService**: fluoxetine 10 MG Oral Capsule [Prozac]**quantity**: 180 {Each}
> **adjudication****category**: Remaining deductible

### Amounts

| | | |
| :--- | :--- | :--- |
| - | **Value** | **Currency** |
| * | 305 | United States dollar |


> **adjudication****category**: Per prescription coinsurance

### Amounts

| | | |
| :--- | :--- | :--- |
| - | **Value** | **Currency** |
| * | 30 | United States dollar |


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

### Amounts

| | | |
| :--- | :--- | :--- |
| - | **Value** | **Currency** |
| * | 70 | United States dollar |





## Resource Content

```json
{
  "resourceType" : "ClaimResponse",
  "id" : "rtpbc-claim-response-01",
  "meta" : {
    "profile" : ["http://hl7.org/fhir/us/carin-rtpbc/StructureDefinition/rtpbc-response-claimresponse"]
  },
  "language" : "en",
  "identifier" : [{
    "value" : "rtpbc-01-response"
  }],
  "status" : "active",
  "type" : {
    "coding" : [{
      "system" : "http://terminology.hl7.org/CodeSystem/claim-type",
      "code" : "pharmacy",
      "display" : "Pharmacy"
    }]
  },
  "use" : "predetermination",
  "patient" : {
    "reference" : "Patient/rtpbc-patient-01"
  },
  "created" : "2025-12-11T11:20:59-05:00",
  "insurer" : {
    "identifier" : {
      "value" : "Pharmacy Plans US"
    }
  },
  "request" : {
    "identifier" : {
      "value" : "rtpbc-01"
    }
  },
  "outcome" : "complete",
  "disposition" : "Processed successfully",
  "item" : [{
    "extension" : [{
      "url" : "http://hl7.org/fhir/us/carin-rtpbc/StructureDefinition/rtpbc-benefitRestriction",
      "valueCoding" : {
        "system" : "http://hl7.org/fhir/us/carin-rtpbc/CodeSystem/rtpbc-benefit-restriction-temporary",
        "code" : "prior-auth",
        "display" : "Prior authorization required"
      }
    },
    {
      "url" : "http://hl7.org/fhir/us/carin-rtpbc/StructureDefinition/rtpbc-formularyStatus",
      "valueCoding" : {
        "system" : "http://hl7.org/fhir/us/carin-rtpbc/CodeSystem/ncpdp-formulary-status-temporary",
        "code" : "O",
        "display" : "On Formulary"
      }
    },
    {
      "url" : "http://hl7.org/fhir/us/carin-rtpbc/StructureDefinition/rtpbc-preferenceLevel",
      "valuePositiveInt" : 2
    },
    {
      "url" : "http://hl7.org/fhir/us/carin-rtpbc/StructureDefinition/rtpbc-nextAvailableFillDate",
      "valueDate" : "2025-12-20"
    }],
    "itemSequence" : 1,
    "adjudication" : [{
      "category" : {
        "coding" : [{
          "system" : "http://hl7.org/fhir/us/carin-rtpbc/CodeSystem/rtpbc-patient-pay-type-temporary",
          "code" : "copay",
          "display" : "Copay"
        }]
      },
      "amount" : {
        "value" : 40,
        "currency" : "USD"
      }
    },
    {
      "category" : {
        "coding" : [{
          "system" : "http://hl7.org/fhir/us/carin-rtpbc/CodeSystem/rtpbc-patient-pay-type-temporary",
          "code" : "coinsurance",
          "display" : "Per prescription coinsurance"
        }]
      },
      "amount" : {
        "value" : 30,
        "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" : 70,
        "currency" : "USD"
      }
    }]
  }],
  "addItem" : [{
    "extension" : [{
      "url" : "http://hl7.org/fhir/us/carin-rtpbc/StructureDefinition/rtpbc-isAlternative",
      "valueBoolean" : true
    },
    {
      "url" : "http://hl7.org/fhir/us/carin-rtpbc/StructureDefinition/rtpbc-benefitRestriction",
      "valueCoding" : {
        "system" : "http://hl7.org/fhir/us/carin-rtpbc/CodeSystem/rtpbc-benefit-restriction-temporary",
        "code" : "covered",
        "display" : "Covered"
      }
    },
    {
      "url" : "http://hl7.org/fhir/us/carin-rtpbc/StructureDefinition/rtpbc-formularyStatus",
      "valueCoding" : {
        "system" : "http://hl7.org/fhir/us/carin-rtpbc/CodeSystem/ncpdp-formulary-status-temporary",
        "code" : "P",
        "display" : "On Formulary/Preferred"
      }
    },
    {
      "url" : "http://hl7.org/fhir/us/carin-rtpbc/StructureDefinition/rtpbc-preferenceLevel",
      "valuePositiveInt" : 1
    }],
    "itemSequence" : [1],
    "provider" : [{
      "reference" : "Organization/rtpbc-organization-03m"
    }],
    "productOrService" : {
      "coding" : [{
        "system" : "http://www.nlm.nih.gov/research/umls/rxnorm",
        "code" : "205535",
        "display" : "fluoxetine 10 MG Oral Capsule [Prozac]"
      }]
    },
    "quantity" : {
      "value" : 180,
      "unit" : "{Each}"
    },
    "adjudication" : [{
      "category" : {
        "coding" : [{
          "system" : "http://hl7.org/fhir/us/carin-rtpbc/CodeSystem/rtpbc-patient-pay-type-temporary",
          "code" : "remaining-deductible",
          "display" : "Remaining deductible"
        }]
      },
      "amount" : {
        "value" : 305,
        "currency" : "USD"
      }
    },
    {
      "category" : {
        "coding" : [{
          "system" : "http://hl7.org/fhir/us/carin-rtpbc/CodeSystem/rtpbc-patient-pay-type-temporary",
          "code" : "coinsurance",
          "display" : "Per prescription coinsurance"
        }]
      },
      "amount" : {
        "value" : 30,
        "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" : 70,
        "currency" : "USD"
      }
    }]
  }]
}

```
