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-price-source

Page standards status: Informative

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    <ClaimResponse xmlns="http://hl7.org/fhir">
      <id value="rtpbc-claim-response-price-source"/>
      <meta>
        <profile
                 value="http://hl7.org/fhir/us/carin-rtpbc/StructureDefinition/rtpbc-response-claimresponse-non-phi"/>
      </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-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>
      </text>
      <identifier>
        <value value="rtpbc-response-price-source"/>
      </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>
        <extension
                   url="http://hl7.org/fhir/StructureDefinition/data-absent-reason">
          <valueCode value="masked"/>
        </extension>
      </patient>
      <created value="2025-11-15T13:10:13-05:00"/>
      <insurer>
        <extension
                   url="http://hl7.org/fhir/StructureDefinition/data-absent-reason">
          <valueCode value="masked"/>
        </extension>
      </insurer>
      <request>
        <identifier>
          <value value="rtpbc-01"/>
        </identifier>
      </request>
      <outcome value="complete"/>
      <disposition value="Processed successfully"/>
      <item>
        <itemSequence value="1"/>
        <noteNumber value="1"/>
        <adjudication>
          <category>
            <coding>
              <system
                      value="http://hl7.org/fhir/us/carin-rtpbc/CodeSystem/rtpbc-patient-pay-type-temporary"/>
              <code value="cash-price"/>
              <display value="Full product cash price"/>
            </coding>
          </category>
          <amount>
            <value value="105"/>
            <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="coupon-discount"/>
              <display value="Coupon discount amount"/>
            </coding>
          </category>
          <amount>
            <value value="-20"/>
            <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="85"/>
            <currency value="USD"/>
          </amount>
        </adjudication>
      </item>
      <addItem>
        <extension
                   url="http://hl7.org/fhir/us/carin-rtpbc/StructureDefinition/rtpbc-isAlternative">
          <valueBoolean value="true"/>
        </extension>
        <itemSequence value="1"/>
        <productOrService>
          <coding>
            <system value="http://www.nlm.nih.gov/research/umls/rxnorm"/>
            <code value="205535"/>
            <display value="fluoxetine 10 MG Oral Capsule [Prozac]"/>
          </coding>
        </productOrService>
        <quantity>
          <value value="60"/>
          <unit value="{Each}"/>
        </quantity>
        <adjudication>
          <category>
            <coding>
              <system
                      value="http://hl7.org/fhir/us/carin-rtpbc/CodeSystem/rtpbc-patient-pay-type-temporary"/>
              <code value="cash-price"/>
              <display value="Full product cash price"/>
            </coding>
          </category>
          <amount>
            <value value="50"/>
            <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="coupon-discount"/>
              <display value="Coupon discount amount"/>
            </coding>
          </category>
          <amount>
            <value value="-10"/>
            <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="40"/>
            <currency value="USD"/>
          </amount>
        </adjudication>
      </addItem>
    </ClaimResponse>