@prefix fhir: . @prefix owl: . @prefix rdf: . @prefix rdfs: . @prefix xsd: . # - resource ------------------------------------------------------------------- a fhir:ClaimResponse ; fhir:nodeRole fhir:treeRoot ; fhir:id [ fhir:v "rtpbc-claim-response-01"] ; # fhir:meta [ fhir:profile ( [ fhir:v "http://hl7.org/fhir/us/carin-rtpbc/StructureDefinition/rtpbc-response-claimresponse"^^xsd:anyURI ; fhir:l ] ) ] ; # fhir:language [ fhir:v "en"] ; # fhir:text [ fhir:status [ fhir:v "extensions" ] ; fhir:div [ fhir:v "

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: 30455)

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
- 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 (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
- 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

"^^rdf:XMLLiteral ] ] ; # fhir:identifier ( [ fhir:value [ fhir:v "rtpbc-01-response" ] ] ) ; # fhir:status [ fhir:v "active"] ; # fhir:type [ fhir:coding ( [ fhir:system [ fhir:v "http://terminology.hl7.org/CodeSystem/claim-type"^^xsd:anyURI ; fhir:l ] ; fhir:code [ fhir:v "pharmacy" ] ; fhir:display [ fhir:v "Pharmacy" ] ] ) ] ; # fhir:use [ fhir:v "predetermination"] ; # fhir:patient [ fhir:l ; fhir:reference [ fhir:v "Patient/rtpbc-patient-01" ] ] ; # fhir:created [ fhir:v "2025-12-11T11:20:59-05:00"^^xsd:dateTime] ; # fhir:insurer [ fhir:identifier [ fhir:value [ fhir:v "Pharmacy Plans US" ] ] ] ; # fhir:request [ fhir:identifier [ fhir:value [ fhir:v "rtpbc-01" ] ] ] ; # fhir:outcome [ fhir:v "complete"] ; # fhir:disposition [ fhir:v "Processed successfully"] ; # fhir:item ( [ fhir:extension ( [ fhir:url [ fhir:v "http://hl7.org/fhir/us/carin-rtpbc/StructureDefinition/rtpbc-benefitRestriction"^^xsd:anyURI ; fhir:l ] ; fhir:value [ a fhir:Coding ; fhir:system [ fhir:v "http://hl7.org/fhir/us/carin-rtpbc/CodeSystem/rtpbc-benefit-restriction-temporary"^^xsd:anyURI ; fhir:l ] ; fhir:code [ fhir:v "prior-auth" ] ; fhir:display [ fhir:v "Prior authorization required" ] ] ] [ fhir:url [ fhir:v "http://hl7.org/fhir/us/carin-rtpbc/StructureDefinition/rtpbc-formularyStatus"^^xsd:anyURI ; fhir:l ] ; fhir:value [ a fhir:Coding ; fhir:system [ fhir:v "http://hl7.org/fhir/us/carin-rtpbc/CodeSystem/ncpdp-formulary-status-temporary"^^xsd:anyURI ; fhir:l ] ; fhir:code [ fhir:v "O" ] ; fhir:display [ fhir:v "On Formulary" ] ] ] [ fhir:url [ fhir:v "http://hl7.org/fhir/us/carin-rtpbc/StructureDefinition/rtpbc-preferenceLevel"^^xsd:anyURI ; fhir:l ] ; fhir:value [ a fhir:PositiveInt ; fhir:v "2"^^xsd:positiveInteger ] ] [ fhir:url [ fhir:v "http://hl7.org/fhir/us/carin-rtpbc/StructureDefinition/rtpbc-nextAvailableFillDate"^^xsd:anyURI ; fhir:l ] ; fhir:value [ a fhir:Date ; fhir:v "2025-12-20"^^xsd:date ] ] ) ; fhir:itemSequence [ fhir:v "1"^^xsd:positiveInteger ] ; fhir:adjudication ( [ fhir:category [ fhir:coding ( [ fhir:system [ fhir:v "http://hl7.org/fhir/us/carin-rtpbc/CodeSystem/rtpbc-patient-pay-type-temporary"^^xsd:anyURI ; fhir:l ] ; fhir:code [ fhir:v "copay" ] ; fhir:display [ fhir:v "Copay" ] ] ) ] ; fhir:amount [ fhir:value [ fhir:v "40"^^xsd:decimal ] ; fhir:currency [ fhir:v "USD" ] ] ] [ fhir:category [ fhir:coding ( [ fhir:system [ fhir:v "http://hl7.org/fhir/us/carin-rtpbc/CodeSystem/rtpbc-patient-pay-type-temporary"^^xsd:anyURI ; fhir:l ] ; fhir:code [ fhir:v "coinsurance" ] ; fhir:display [ fhir:v "Per prescription coinsurance" ] ] ) ] ; fhir:amount [ fhir:value [ fhir:v "30"^^xsd:decimal ] ; fhir:currency [ fhir:v "USD" ] ] ] [ fhir:category [ fhir:coding ( [ fhir:system [ fhir:v "http://hl7.org/fhir/us/carin-rtpbc/CodeSystem/rtpbc-patient-pay-type-temporary"^^xsd:anyURI ; fhir:l ] ; fhir:code [ fhir:v "total" ] ; fhir:display [ fhir:v "Total patient responsibility" ] ] ) ] ; fhir:amount [ fhir:value [ fhir:v "70"^^xsd:decimal ] ; fhir:currency [ fhir:v "USD" ] ] ] ) ] ) ; # fhir:addItem ( [ fhir:extension ( [ fhir:url [ fhir:v "http://hl7.org/fhir/us/carin-rtpbc/StructureDefinition/rtpbc-isAlternative"^^xsd:anyURI ; fhir:l ] ; fhir:value [ a fhir:Boolean ; fhir:v true ] ] [ fhir:url [ fhir:v "http://hl7.org/fhir/us/carin-rtpbc/StructureDefinition/rtpbc-benefitRestriction"^^xsd:anyURI ; fhir:l ] ; fhir:value [ a fhir:Coding ; fhir:system [ fhir:v "http://hl7.org/fhir/us/carin-rtpbc/CodeSystem/rtpbc-benefit-restriction-temporary"^^xsd:anyURI ; fhir:l ] ; fhir:code [ fhir:v "covered" ] ; fhir:display [ fhir:v "Covered" ] ] ] [ fhir:url [ fhir:v "http://hl7.org/fhir/us/carin-rtpbc/StructureDefinition/rtpbc-formularyStatus"^^xsd:anyURI ; fhir:l ] ; fhir:value [ a fhir:Coding ; fhir:system [ fhir:v "http://hl7.org/fhir/us/carin-rtpbc/CodeSystem/ncpdp-formulary-status-temporary"^^xsd:anyURI ; fhir:l ] ; fhir:code [ fhir:v "P" ] ; fhir:display [ fhir:v "On Formulary/Preferred" ] ] ] [ fhir:url [ fhir:v "http://hl7.org/fhir/us/carin-rtpbc/StructureDefinition/rtpbc-preferenceLevel"^^xsd:anyURI ; fhir:l ] ; fhir:value [ a fhir:PositiveInt ; fhir:v "1"^^xsd:positiveInteger ] ] ) ; fhir:itemSequence ( [ fhir:v "1"^^xsd:positiveInteger ] ) ; fhir:provider ( [ fhir:l ; fhir:reference [ fhir:v "Organization/rtpbc-organization-03m" ] ] ) ; fhir:productOrService [ fhir:coding ( [ fhir:system [ fhir:v "http://www.nlm.nih.gov/research/umls/rxnorm"^^xsd:anyURI ; fhir:l ] ; fhir:code [ fhir:v "205535" ] ; fhir:display [ fhir:v "fluoxetine 10 MG Oral Capsule [Prozac]" ] ] ) ] ; fhir:quantity [ fhir:value [ fhir:v "180"^^xsd:decimal ] ; fhir:unit [ fhir:v "{Each}" ] ] ; fhir:adjudication ( [ fhir:category [ fhir:coding ( [ fhir:system [ fhir:v "http://hl7.org/fhir/us/carin-rtpbc/CodeSystem/rtpbc-patient-pay-type-temporary"^^xsd:anyURI ; fhir:l ] ; fhir:code [ fhir:v "remaining-deductible" ] ; fhir:display [ fhir:v "Remaining deductible" ] ] ) ] ; fhir:amount [ fhir:value [ fhir:v "305"^^xsd:decimal ] ; fhir:currency [ fhir:v "USD" ] ] ] [ fhir:category [ fhir:coding ( [ fhir:system [ fhir:v "http://hl7.org/fhir/us/carin-rtpbc/CodeSystem/rtpbc-patient-pay-type-temporary"^^xsd:anyURI ; fhir:l ] ; fhir:code [ fhir:v "coinsurance" ] ; fhir:display [ fhir:v "Per prescription coinsurance" ] ] ) ] ; fhir:amount [ fhir:value [ fhir:v "30"^^xsd:decimal ] ; fhir:currency [ fhir:v "USD" ] ] ] [ fhir:category [ fhir:coding ( [ fhir:system [ fhir:v "http://hl7.org/fhir/us/carin-rtpbc/CodeSystem/rtpbc-patient-pay-type-temporary"^^xsd:anyURI ; fhir:l ] ; fhir:code [ fhir:v "total" ] ; fhir:display [ fhir:v "Total patient responsibility" ] ] ) ] ; fhir:amount [ fhir:value [ fhir:v "70"^^xsd:decimal ] ; fhir:currency [ fhir:v "USD" ] ] ] ) ] ) . # a fhir:Us . a fhir:Us . # -------------------------------------------------------------------------------------