Consumer Real-Time Pharmacy Benefit Check FHIR IG
2.0.0-ballot - STU 2 Ballot

Consumer Real-Time Pharmacy Benefit Check FHIR IG, published by HL7 International / Pharmacy. This guide is not an authorized publication; it is the continuous build for version 2.0.0-ballot built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/HL7/carin-rtpbc/ and changes regularly. See the Directory of published versions

## : rtpbc-claim-response-not-covered

Page standards status: Informative

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    <ClaimResponse xmlns="http://hl7.org/fhir">
      <id value="rtpbc-claim-response-not-covered"/>
      <meta>
        <profile
                 value="http://hl7.org/fhir/us/carin-rtpbc/StructureDefinition/rtpbc-response-claimresponse"/>
      </meta>
      <language value="en"/>
      <text>
        <status value="extensions"/>
        <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-not-covered</b></p><a name="rtpbc-claim-response-not-covered"> </a><a name="hcrtpbc-claim-response-not-covered"> </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.html">RTPBC Response Using ClaimResponse</a></p></div><p><b>identifier</b>: rtpbc-03-response-c-r</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>: <a href="Patient-rtpbc-patient-01.html">Jane Doe  Female, DoB: 1975-12-05 ( Patient internal identifier: 30455)</a></p><p><b>created</b>: 2019-11-01 11:20:59-0500</p><p><b>insurer</b>: Identifier: Pharmacy Plans US</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>RTPBC benefitRestriction Extension</b>: <a href="CodeSystem-rtpbc-benefit-restriction-temporary.html#rtpbc-benefit-restriction-temporary-not-covered">RTPBC Benefit Restriction Code System (Temporary): not-covered</a> (Not covered)</p><p><b>itemSequence</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 eligible}">Eligible 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>0</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>RTPBC benefitRestriction Extension</b>: <a href="CodeSystem-rtpbc-benefit-restriction-temporary.html#rtpbc-benefit-restriction-temporary-prior-auth">RTPBC Benefit Restriction Code System (Temporary): prior-auth</a> (Prior authorization required)</p><p><b>RTPBC benefitRestriction Extension</b>: <a href="CodeSystem-rtpbc-benefit-restriction-temporary.html#rtpbc-benefit-restriction-temporary-quantity-limit">RTPBC Benefit Restriction Code System (Temporary): quantity-limit</a> (Quantity limit applies)</p><p><b>itemSequence</b>: 1</p><p><b>provider</b>: <a href="Organization-rtpbc-organization-03m.html">Organization My Mail Service Pharmacy</a></p><p><b>productOrService</b>: <span title="Codes:{http://www.nlm.nih.gov/research/umls/rxnorm 1734642}">elbasvir 50 MG / grazoprevir 100 MG Oral Tablet [Zepatier]</span></p><p><b>quantity</b>: 28 {Each}</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 copay}">Copay</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>405</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 coinsurance}">Per prescription coinsurance</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>469</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>874</td><td>United States dollar</td></tr></table></blockquote></blockquote><h3>ProcessNotes</h3><table class="grid"><tr><td style="display: none">-</td><td><b>Number</b></td><td><b>Text</b></td></tr><tr><td style="display: none">*</td><td>1</td><td>Quantity limit: 28 tablets per month</td></tr></table></div>
      </text>
      <identifier>
        <value value="rtpbc-03-response-c-r"/>
      </identifier>
      <status value="active"/>
      <type>
        <coding>
          <system value="http://terminology.hl7.org/CodeSystem/claim-type"/>
          <code value="pharmacy"/>
          <display value="Pharmacy"/>
        </coding>
      </type>
      <use value="predetermination"/>
      <patient>🔗
        <reference value="Patient/rtpbc-patient-01"/>
      </patient>
      <created value="2019-11-01T11:20:59-05:00"/>
      <insurer>
        <identifier>
          <value value="Pharmacy Plans US"/>
        </identifier>
      </insurer>
      <request>
        <identifier>
          <value value="rtpbc-01"/>
        </identifier>
      </request>
      <outcome value="complete"/>
      <disposition value="Processed successfully"/>
      <item>
        <extension
                   url="http://hl7.org/fhir/us/carin-rtpbc/StructureDefinition/rtpbc-benefitRestriction">
          <valueCoding>
            <system
                    value="http://hl7.org/fhir/us/carin-rtpbc/CodeSystem/rtpbc-benefit-restriction-temporary"/>
            <code value="not-covered"/>
            <display value="Not covered"/>
          </valueCoding>
        </extension>
        <itemSequence value="1"/>
        <adjudication>
          <category>
            <coding>
              <system
                      value="http://hl7.org/fhir/us/carin-rtpbc/CodeSystem/rtpbc-patient-pay-type-temporary"/>
              <code value="eligible"/>
              <display value="Eligible amount"/>
            </coding>
          </category>
          <amount>
            <value value="0"/>
            <currency value="USD"/>
          </amount>
        </adjudication>
      </item>
      <addItem>
        <extension
                   url="http://hl7.org/fhir/us/carin-rtpbc/StructureDefinition/rtpbc-isAlternative">
          <valueBoolean value="true"/>
        </extension>
        <extension
                   url="http://hl7.org/fhir/us/carin-rtpbc/StructureDefinition/rtpbc-benefitRestriction">
          <valueCoding>
            <system
                    value="http://hl7.org/fhir/us/carin-rtpbc/CodeSystem/rtpbc-benefit-restriction-temporary"/>
            <code value="prior-auth"/>
            <display value="Prior authorization required"/>
          </valueCoding>
        </extension>
        <extension
                   url="http://hl7.org/fhir/us/carin-rtpbc/StructureDefinition/rtpbc-benefitRestriction">
          <valueCoding>
            <system
                    value="http://hl7.org/fhir/us/carin-rtpbc/CodeSystem/rtpbc-benefit-restriction-temporary"/>
            <code value="quantity-limit"/>
            <display value="Quantity limit applies"/>
          </valueCoding>
        </extension>
        <itemSequence value="1"/>
        <provider>🔗
          <reference value="Organization/rtpbc-organization-03m"/>
        </provider>
        <productOrService>
          <coding>
            <system value="http://www.nlm.nih.gov/research/umls/rxnorm"/>
            <code value="1734642"/>
            <display
                     value="elbasvir 50 MG / grazoprevir 100 MG Oral Tablet [Zepatier]"/>
          </coding>
        </productOrService>
        <quantity>
          <value value="28"/>
          <unit value="{Each}"/>
        </quantity>
        <noteNumber value="1"/>
        <adjudication>
          <category>
            <coding>
              <system
                      value="http://hl7.org/fhir/us/carin-rtpbc/CodeSystem/rtpbc-patient-pay-type-temporary"/>
              <code value="copay"/>
              <display value="Copay"/>
            </coding>
          </category>
          <amount>
            <value value="405"/>
            <currency value="USD"/>
          </amount>
        </adjudication>
        <adjudication>
          <category>
            <coding>
              <system
                      value="http://hl7.org/fhir/us/carin-rtpbc/CodeSystem/rtpbc-patient-pay-type-temporary"/>
              <code value="coinsurance"/>
              <display value="Per prescription coinsurance"/>
            </coding>
          </category>
          <amount>
            <value value="469"/>
            <currency value="USD"/>
          </amount>
        </adjudication>
        <adjudication>
          <category>
            <coding>
              <system
                      value="http://hl7.org/fhir/us/carin-rtpbc/CodeSystem/rtpbc-patient-pay-type-temporary"/>
              <code value="total"/>
              <display value="Total patient responsibility"/>
            </coding>
          </category>
          <amount>
            <value value="874"/>
            <currency value="USD"/>
          </amount>
        </adjudication>
      </addItem>
      <processNote>
        <number value="1"/>
        <text value="Quantity limit: 28 tablets per month"/>
      </processNote>
    </ClaimResponse>