# RTPBC Request Using Claim - Non-PHI - Consumer Real-Time Pharmacy Benefit Check FHIR IG v2.0.0-ballot

## Resource Profile: RTPBC Request Using Claim - Non-PHI 

 
This profile provides minimal, non-persoanlly-identifiable content for submission in an RTPBC request to data sources that can provide benefit or price information without receiving patient details. 

This profile constrains the Claim resource to serve as an anonymous request to RTPBC endpoints that don't require personally-identifiable, protected healthcare information to provide their response. Examples include cash price sources or discount card companies.

Data population is based on the [RTPBC Request Using Claim](StructureDefinition-rtpbc-request-claim.md) but excludes elements that could contain information about the patient or related information that could potentially be used to re-identify the patient (such as the patient's care provider or insurance identifiers).

### Masked information

The following elements are unavailable in this profile:

* patient
* careTeam
* insurer
* insurance.coverage

In cases where the element to be masked is required by the base Claim resource, the Data Absent Reason extension is to be used with the code, "masked". §PHI-CLM-1:To conform with the Non-PHI Coverage profile, the Data Absent Reason extension **SHALL** be used in the Claim.patient and Claim.insurance.coverage elements, populated with the code, "masked".§

In cases where the element to be masked is optional in the base Claim resource, this profile sets the cardinality to 0..0.

### Preferred pharmacy - specific or geographic area

This profile enables the patient to state their pharmacy preference by either specifying a particular pharmacy or describing a geographic area in terms of one or more postal codes.

* Specific pharmacy: Reference a pharmacy (Organization resource) in Claim.provider
* Geographic area: Use the preferredPharmacyPostalCode extension in Claim.provider. §MS-CLM-1:The preferredPharmacyPostalCode extension **MAY** be repeated to specify multiple postal codes.§ §MS-CLM-2:An RTPBC Responder **SHALL** consider all preferredPharmacyPostalCode values submitted in a request.§

### Support for an anonymous patient identifier

§PHI-CLM-2:The patient.identifier element in this profile is available to be populated but **SHALL** contain only non-personally-identifiable codes, such as an account or user ID assigned during an anonymous interaction with the server.§

**Usages:**

* Use this Profile: [RTPBC Request Bundle - Non-PHI](StructureDefinition-rtpbc-request-bundle-non-phi.md)
* Refer to this Profile: [RTPBC Non-PHI Request MessageHeader](StructureDefinition-rtpbc-request-messageheader-non-phi.md)
* Examples for this Profile: [Claim/rtpbc-claim-non-phi-1](Claim-rtpbc-claim-non-phi-1.md) and [Claim/rtpbc-claim-non-phi-2](Claim-rtpbc-claim-non-phi-2.md)

You can also check for [usages in the FHIR IG Statistics](https://packages2.fhir.org/xig/hl7.fhir.us.carin-rtpbc|current/StructureDefinition/rtpbc-request-claim-non-phi)

### Formal Views of Profile Content

 [Description Differentials, Snapshots, and other representations](http://build.fhir.org/ig/FHIR/ig-guidance/readingIgs.html#structure-definitions). 

 

Other representations of profile: [CSV](../StructureDefinition-rtpbc-request-claim-non-phi.csv), [Excel](../StructureDefinition-rtpbc-request-claim-non-phi.xlsx), [Schematron](../StructureDefinition-rtpbc-request-claim-non-phi.sch) 



## Resource Content

```json
{
  "resourceType" : "StructureDefinition",
  "id" : "rtpbc-request-claim-non-phi",
  "extension" : [{
    "url" : "http://hl7.org/fhir/StructureDefinition/structuredefinition-wg",
    "valueCode" : "phx"
  },
  {
    "url" : "http://hl7.org/fhir/StructureDefinition/structuredefinition-fmm",
    "valueInteger" : 2,
    "_valueInteger" : {
      "extension" : [{
        "url" : "http://hl7.org/fhir/StructureDefinition/structuredefinition-conformance-derivedFrom",
        "valueCanonical" : "http://hl7.org/fhir/us/carin-rtpbc/ImplementationGuide/hl7.fhir.us.carin-rtpbc"
      }]
    }
  },
  {
    "url" : "http://hl7.org/fhir/StructureDefinition/structuredefinition-standards-status",
    "valueCode" : "trial-use",
    "_valueCode" : {
      "extension" : [{
        "url" : "http://hl7.org/fhir/StructureDefinition/structuredefinition-conformance-derivedFrom",
        "valueCanonical" : "http://hl7.org/fhir/us/carin-rtpbc/ImplementationGuide/hl7.fhir.us.carin-rtpbc"
      }]
    }
  }],
  "url" : "http://hl7.org/fhir/us/carin-rtpbc/StructureDefinition/rtpbc-request-claim-non-phi",
  "version" : "2.0.0-ballot",
  "name" : "RtpbcRequestClaimNonPHI",
  "title" : "RTPBC Request Using Claim - Non-PHI",
  "status" : "active",
  "date" : "2025-12-12T00:00:00-05:00",
  "publisher" : "HL7 International / Pharmacy",
  "contact" : [{
    "name" : "HL7 International / Pharmacy",
    "telecom" : [{
      "system" : "url",
      "value" : "http://www.hl7.org/Special/committees/medication"
    }]
  },
  {
    "name" : "Frank McKinney",
    "telecom" : [{
      "system" : "email",
      "value" : "fm@frankmckinney.com"
    }]
  }],
  "description" : "This profile provides minimal, non-persoanlly-identifiable content for submission in an RTPBC request to data sources that can provide benefit or price information without receiving patient details.",
  "jurisdiction" : [{
    "coding" : [{
      "system" : "urn:iso:std:iso:3166",
      "code" : "US",
      "display" : "United States of America"
    }]
  }],
  "fhirVersion" : "4.0.1",
  "mapping" : [{
    "identity" : "workflow",
    "uri" : "http://hl7.org/fhir/workflow",
    "name" : "Workflow Pattern"
  },
  {
    "identity" : "w5",
    "uri" : "http://hl7.org/fhir/fivews",
    "name" : "FiveWs Pattern Mapping"
  },
  {
    "identity" : "rim",
    "uri" : "http://hl7.org/v3",
    "name" : "RIM Mapping"
  }],
  "kind" : "resource",
  "abstract" : false,
  "type" : "Claim",
  "baseDefinition" : "http://hl7.org/fhir/StructureDefinition/Claim",
  "derivation" : "constraint",
  "differential" : {
    "element" : [{
      "id" : "Claim.id",
      "path" : "Claim.id",
      "label" : "Unique Claim Resource Identifier",
      "short" : "Unique Claim Resource Identifier",
      "definition" : "Unique Claim Resource Identifier assigned by the submitting patient application",
      "min" : 1,
      "mustSupport" : true
    },
    {
      "id" : "Claim.identifier",
      "path" : "Claim.identifier",
      "label" : "RTPBC request identifier",
      "short" : "RTPBC request identifier",
      "min" : 1,
      "max" : "1",
      "mustSupport" : true
    },
    {
      "id" : "Claim.identifier.value",
      "path" : "Claim.identifier.value",
      "label" : "Unique RTPBC request ID",
      "short" : "Unique RTPBC request ID",
      "definition" : "An identifier for each RTPBC request that is assigned by and unique to the submitter",
      "min" : 1,
      "mustSupport" : true
    },
    {
      "id" : "Claim.status",
      "path" : "Claim.status",
      "label" : "Request status",
      "short" : "Request status",
      "definition" : "The status of this request (active)",
      "comment" : "Value is always 'active'",
      "fixedCode" : "active",
      "mustSupport" : true
    },
    {
      "id" : "Claim.type",
      "path" : "Claim.type",
      "label" : "Requested Service Type",
      "short" : "Requested Service Type",
      "definition" : "The type of service for which pricing and coverage predetermination is being requested",
      "comment" : "Value is always 'pharmacy'",
      "mustSupport" : true
    },
    {
      "id" : "Claim.type.coding",
      "path" : "Claim.type.coding",
      "min" : 1,
      "max" : "1",
      "mustSupport" : true
    },
    {
      "id" : "Claim.type.coding.system",
      "path" : "Claim.type.coding.system",
      "min" : 1,
      "fixedUri" : "http://terminology.hl7.org/CodeSystem/claim-type",
      "mustSupport" : true
    },
    {
      "id" : "Claim.type.coding.code",
      "path" : "Claim.type.coding.code",
      "min" : 1,
      "fixedCode" : "pharmacy",
      "mustSupport" : true
    },
    {
      "id" : "Claim.type.coding.display",
      "path" : "Claim.type.coding.display",
      "min" : 1,
      "fixedString" : "Pharmacy",
      "mustSupport" : true
    },
    {
      "id" : "Claim.use",
      "path" : "Claim.use",
      "label" : "Processing Mode",
      "short" : "Processing Mode",
      "definition" : "The mode of processing being requested of the payer/PBM",
      "comment" : "Value is always 'predetermination'",
      "fixedCode" : "predetermination",
      "mustSupport" : true
    },
    {
      "id" : "Claim.patient",
      "path" : "Claim.patient",
      "label" : "Patient information (masked)",
      "short" : "Patient information (masked)",
      "definition" : "No personally-identifiable information is included in this profile. Instead, the patient element is populated with a Data Absent Reason = 'masked'"
    },
    {
      "id" : "Claim.patient.extension",
      "path" : "Claim.patient.extension",
      "min" : 1,
      "mustSupport" : true
    },
    {
      "id" : "Claim.patient.extension:data-masked",
      "path" : "Claim.patient.extension",
      "sliceName" : "data-masked",
      "min" : 1,
      "max" : "1",
      "type" : [{
        "code" : "Extension",
        "profile" : ["http://hl7.org/fhir/StructureDefinition/data-absent-reason|5.2.0"]
      }],
      "mustSupport" : true
    },
    {
      "id" : "Claim.patient.extension:data-masked.value[x]",
      "path" : "Claim.patient.extension.value[x]",
      "fixedCode" : "masked"
    },
    {
      "id" : "Claim.patient.reference",
      "path" : "Claim.patient.reference",
      "max" : "0"
    },
    {
      "id" : "Claim.patient.type",
      "path" : "Claim.patient.type",
      "max" : "0"
    },
    {
      "id" : "Claim.patient.identifier",
      "path" : "Claim.patient.identifier",
      "label" : "Unique, non-personally identifiable code",
      "short" : "Unique, non-personally identifiable code",
      "definition" : "A unique, non-personally identifiable code such as an anonymous account identifier",
      "comment" : "The patient.identifier element in this profile is limited to only non-personally-identifiable codes, such as an account or user ID assigned during an anonymous interaction with the server."
    },
    {
      "id" : "Claim.patient.display",
      "path" : "Claim.patient.display",
      "max" : "0"
    },
    {
      "id" : "Claim.created",
      "path" : "Claim.created",
      "label" : "Created DateTime",
      "short" : "Created DateTime",
      "definition" : "The date and time on which this RTBPC request was created",
      "mustSupport" : true
    },
    {
      "id" : "Claim.insurer",
      "path" : "Claim.insurer",
      "label" : "Insurer (masked)",
      "short" : "Insurer (masked)",
      "definition" : "No personally-identifiable information is included in this profile. Insurance information is not included because it could potentially be used to re-identify patients",
      "max" : "0"
    },
    {
      "id" : "Claim.provider",
      "path" : "Claim.provider",
      "label" : "Preferred Pharmacy",
      "short" : "Preferred Pharmacy",
      "definition" : "The patient's preferred pharmacy to be considered during creation of the response.",
      "comment" : "Either a specific pharmacy or the preferred geographic area (using preferredPharmacyPostalCode) must be present",
      "type" : [{
        "code" : "Reference",
        "targetProfile" : ["http://hl7.org/fhir/us/carin-rtpbc/StructureDefinition/rtpbc-pharmacy-organization"]
      }],
      "mustSupport" : true
    },
    {
      "id" : "Claim.provider.extension:preferred-pharmacy-postal-code",
      "path" : "Claim.provider.extension",
      "sliceName" : "preferred-pharmacy-postal-code",
      "short" : "Preferred Pharmacy Postal Code (Extension)",
      "definition" : "Specifies the preferred geographic area for the dispensing pharmacy using a postal code",
      "comment" : "Used when a specific pharmacy is not populated.",
      "min" : 0,
      "max" : "*",
      "type" : [{
        "code" : "Extension",
        "profile" : ["http://hl7.org/fhir/us/carin-rtpbc/StructureDefinition/rtpbc-preferredPharmacyPostalCode"]
      }],
      "mustSupport" : true
    },
    {
      "id" : "Claim.provider.reference",
      "path" : "Claim.provider.reference",
      "label" : "Reference to Pharmacy Organization",
      "short" : "Reference to Pharmacy Organization",
      "definition" : "Reference to an Organization resource representing the patient's preferred pharmacy",
      "mustSupport" : true
    },
    {
      "id" : "Claim.priority",
      "path" : "Claim.priority",
      "label" : "Processing priority",
      "short" : "Processing priority",
      "definition" : "The processing priority requested of the payer/PBM",
      "comment" : "All requests are responded to in real-time, without differentiated priority levels. Value is always 'normal'",
      "mustSupport" : true
    },
    {
      "id" : "Claim.priority.coding",
      "path" : "Claim.priority.coding",
      "min" : 1,
      "max" : "1",
      "mustSupport" : true
    },
    {
      "id" : "Claim.priority.coding.system",
      "path" : "Claim.priority.coding.system",
      "min" : 1,
      "fixedUri" : "http://terminology.hl7.org/CodeSystem/processpriority",
      "mustSupport" : true
    },
    {
      "id" : "Claim.priority.coding.code",
      "path" : "Claim.priority.coding.code",
      "min" : 1,
      "fixedCode" : "normal",
      "mustSupport" : true
    },
    {
      "id" : "Claim.priority.coding.display",
      "path" : "Claim.priority.coding.display",
      "min" : 1,
      "fixedString" : "Normal",
      "mustSupport" : true
    },
    {
      "id" : "Claim.prescription",
      "path" : "Claim.prescription",
      "label" : "Prescription (masked)",
      "short" : "Prescription (masked)",
      "definition" : "No personally-identifiable information is included in this profile.",
      "max" : "0"
    },
    {
      "id" : "Claim.careTeam",
      "path" : "Claim.careTeam",
      "label" : "Care team information (masked)",
      "short" : "Care team information (masked)",
      "definition" : "No personally-identifiable information is included in this profile. Care team information is not included because it can be used to re-identify patients in some circumstances",
      "max" : "0"
    },
    {
      "id" : "Claim.insurance",
      "path" : "Claim.insurance",
      "label" : "Patient insurance information (masked)",
      "short" : "Patient insurance information (masked)",
      "comment" : "Only one set of coverage is submitted in the request. Value is always '1'",
      "max" : "1"
    },
    {
      "id" : "Claim.insurance.sequence",
      "path" : "Claim.insurance.sequence",
      "fixedPositiveInt" : 1
    },
    {
      "id" : "Claim.insurance.focal",
      "path" : "Claim.insurance.focal",
      "comment" : "No insurance coverage information is contained in this profile because it can contain identifiers that can be used to re-identify patients",
      "fixedBoolean" : false
    },
    {
      "id" : "Claim.insurance.coverage",
      "path" : "Claim.insurance.coverage",
      "label" : "Insurance Coverage Masked",
      "short" : "Insurance Coverage Masked",
      "definition" : "No personally-identifiable information is included in this profile. Insurance information is not included because it can contain identifiers that can be used to re-identify patients. Instead, the insurance element is populated with a Data Absent Reason = 'masked'"
    },
    {
      "id" : "Claim.insurance.coverage.extension",
      "path" : "Claim.insurance.coverage.extension",
      "min" : 1,
      "mustSupport" : true
    },
    {
      "id" : "Claim.insurance.coverage.extension:data-masked",
      "path" : "Claim.insurance.coverage.extension",
      "sliceName" : "data-masked",
      "min" : 1,
      "max" : "1",
      "type" : [{
        "code" : "Extension",
        "profile" : ["http://hl7.org/fhir/StructureDefinition/data-absent-reason|5.2.0"]
      }],
      "mustSupport" : true
    },
    {
      "id" : "Claim.insurance.coverage.extension:data-masked.value[x]",
      "path" : "Claim.insurance.coverage.extension.value[x]",
      "fixedCode" : "masked"
    },
    {
      "id" : "Claim.insurance.coverage.reference",
      "path" : "Claim.insurance.coverage.reference",
      "max" : "0"
    },
    {
      "id" : "Claim.insurance.coverage.type",
      "path" : "Claim.insurance.coverage.type",
      "max" : "0"
    },
    {
      "id" : "Claim.insurance.coverage.identifier",
      "path" : "Claim.insurance.coverage.identifier",
      "max" : "0"
    },
    {
      "id" : "Claim.insurance.coverage.display",
      "path" : "Claim.insurance.coverage.display",
      "max" : "0"
    },
    {
      "id" : "Claim.item",
      "path" : "Claim.item",
      "label" : "Max 1 item per request",
      "short" : "Max 1 item per request",
      "min" : 1,
      "max" : "1",
      "mustSupport" : true
    },
    {
      "id" : "Claim.item.sequence",
      "path" : "Claim.item.sequence",
      "comment" : "A maximum of one product is submitted per request. Value is always '1'",
      "fixedPositiveInt" : 1,
      "mustSupport" : true
    },
    {
      "id" : "Claim.item.careTeamSequence",
      "path" : "Claim.item.careTeamSequence",
      "comment" : "No personally-identifiable information is included in this profile. Care team information is not included because it can be used to re-identify patients in some circumstances",
      "max" : "0"
    },
    {
      "id" : "Claim.item.productOrService",
      "path" : "Claim.item.productOrService",
      "label" : "Prescribed Product",
      "short" : "Prescribed Product",
      "definition" : "A product identifier for the prescribed medication. Either an NDC11 or an RxNorm code for a prescribable product (representing drug name, strength and dose form)",
      "comment" : "The NDC11 is an 11-digit normalized format consisting of a 5-digit labeler segment, 4-digit product segment, and 2-digit package segment, with no dashes",
      "mustSupport" : true,
      "binding" : {
        "strength" : "extensible",
        "description" : "RTPBC prescribable product codes (NDC11 and RxNorm)",
        "valueSet" : "http://hl7.org/fhir/us/carin-rtpbc/ValueSet/rtpbc-prescribable-product-code"
      }
    },
    {
      "id" : "Claim.item.productOrService.coding",
      "path" : "Claim.item.productOrService.coding",
      "mustSupport" : true
    },
    {
      "id" : "Claim.item.productOrService.coding.system",
      "path" : "Claim.item.productOrService.coding.system",
      "mustSupport" : true
    },
    {
      "id" : "Claim.item.productOrService.coding.code",
      "path" : "Claim.item.productOrService.coding.code",
      "mustSupport" : true
    },
    {
      "id" : "Claim.item.productOrService.coding.display",
      "path" : "Claim.item.productOrService.coding.display",
      "label" : "Product Description",
      "short" : "Product Description",
      "definition" : "The full prescribable product name, including drug name, strength and dose form. The drug name equals the brand name if the branded product is desired",
      "mustSupport" : true
    },
    {
      "id" : "Claim.item.productOrService.text",
      "path" : "Claim.item.productOrService.text",
      "mustSupport" : true
    },
    {
      "id" : "Claim.item.quantity",
      "path" : "Claim.item.quantity",
      "label" : "Prescribed Quantity",
      "short" : "Prescribed Quantity",
      "min" : 1,
      "mustSupport" : true
    },
    {
      "id" : "Claim.item.quantity.value",
      "path" : "Claim.item.quantity.value",
      "label" : "Quantity in Billing Units",
      "short" : "Quantity in Billing Units",
      "definition" : "The prescribed quantity in terms of the applicable billing unit of measure",
      "min" : 1,
      "mustSupport" : true
    },
    {
      "id" : "Claim.item.quantity.unit",
      "path" : "Claim.item.quantity.unit",
      "label" : "Billing unit of measure",
      "short" : "Billing unit of measure",
      "definition" : "Pharmacy metric billing unit: GM (gram), ML (milliliter) or EA (each)",
      "min" : 1,
      "mustSupport" : true,
      "binding" : {
        "strength" : "extensible",
        "description" : "Billing quantity unit of measure",
        "valueSet" : "http://hl7.org/fhir/us/carin-rtpbc/ValueSet/rtpbc-billing-unit"
      }
    }]
  }
}

```
