{
  "resourceType" : "ClaimResponse",
  "id" : "rtpbc-claim-response-not-covered",
  "meta" : {
    "profile" : ["http://hl7.org/fhir/us/carin-rtpbc/StructureDefinition/rtpbc-response-claimresponse"]
  },
  "language" : "en",
  "text" : {
    "status" : "extensions",
    "div" : "<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:\u00a030455)</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>"
  },
  "identifier" : [{
    "value" : "rtpbc-03-response-c-r"
  }],
  "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" : "2019-11-01T11:20:59-05:00",
  "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" : "not-covered",
        "display" : "Not covered"
      }
    }],
    "itemSequence" : 1,
    "adjudication" : [{
      "category" : {
        "coding" : [{
          "system" : "http://hl7.org/fhir/us/carin-rtpbc/CodeSystem/rtpbc-patient-pay-type-temporary",
          "code" : "eligible",
          "display" : "Eligible amount"
        }]
      },
      "amount" : {
        "value" : 0,
        "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" : "prior-auth",
        "display" : "Prior authorization required"
      }
    },
    {
      "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" : "quantity-limit",
        "display" : "Quantity limit applies"
      }
    }],
    "itemSequence" : [1],
    "provider" : [{
      "reference" : "Organization/rtpbc-organization-03m"
    }],
    "productOrService" : {
      "coding" : [{
        "system" : "http://www.nlm.nih.gov/research/umls/rxnorm",
        "code" : "1734642",
        "display" : "elbasvir 50 MG / grazoprevir 100 MG Oral Tablet [Zepatier]"
      }]
    },
    "quantity" : {
      "value" : 28,
      "unit" : "{Each}"
    },
    "noteNumber" : [1],
    "adjudication" : [{
      "category" : {
        "coding" : [{
          "system" : "http://hl7.org/fhir/us/carin-rtpbc/CodeSystem/rtpbc-patient-pay-type-temporary",
          "code" : "copay",
          "display" : "Copay"
        }]
      },
      "amount" : {
        "value" : 405,
        "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" : 469,
        "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" : 874,
        "currency" : "USD"
      }
    }]
  }],
  "processNote" : [{
    "number" : 1,
    "text" : "Quantity limit: 28 tablets per month"
  }]
}