{ "resourceType" : "ClaimResponse", "id" : "rtpbc-claim-response-01", "meta" : { "profile" : ["http://hl7.org/fhir/us/carin-rtpbc/StructureDefinition/rtpbc-response-claimresponse"] }, "language" : "en", "text" : { "status" : "extensions", "div" : "

Generated Narrative: ClaimResponse rtpbc-claim-response-01

Language: en

Profile: RTPBC Response Using ClaimResponse

identifier: rtpbc-01-response

status: Active

type: Pharmacy

use: Predetermination

patient: Jane Doe Female, DoB: 1975-12-05 ( Patient internal identifier:\u00a030455)

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 (Prior authorization required)

RTPBC formularyStatus Extension: NCPDP Formulary Status Code System (Temporary): O (On Formulary)

RTPBC preferenceLevel Extension: 2

RTPBC nextAvailableFillDate Extension: 2025-12-20

itemSequence: 1

adjudication

category: Copay

Amounts

-ValueCurrency
*40United States dollar

adjudication

category: Per prescription coinsurance

Amounts

-ValueCurrency
*30United States dollar

adjudication

category: Total patient responsibility

Amounts

-ValueCurrency
*70United States dollar

addItem

RTPBC isAlternative Extension: true

RTPBC benefitRestriction Extension: RTPBC Benefit Restriction Code System (Temporary): covered (Covered)

RTPBC formularyStatus Extension: NCPDP Formulary Status Code System (Temporary): P (On Formulary/Preferred)

RTPBC preferenceLevel Extension: 1

itemSequence: 1

provider: Organization My Mail Service Pharmacy

productOrService: fluoxetine 10 MG Oral Capsule [Prozac]

quantity: 180 {Each}

adjudication

category: Remaining deductible

Amounts

-ValueCurrency
*305United States dollar

adjudication

category: Per prescription coinsurance

Amounts

-ValueCurrency
*30United States dollar

adjudication

category: Total patient responsibility

Amounts

-ValueCurrency
*70United States dollar
" }, "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" } }] }] }