This resource provides the adjudication details from the processing of a Claim resource.

Unique ClaimResponse Resource Identifier assigned by the responding payer/PBM

The only time that a resource does not have an id is when it is being submitted to the server using a create operation.

A reference to a set of rules that were followed when the resource was constructed, and which must be understood when processing the content. Often, this is a reference to an implementation guide that defines the special rules along with other profiles etc.

Asserting this rule set restricts the content to be only understood by a limited set of trading partners. This inherently limits the usefulness of the data in the long term. However, the existing health eco-system is highly fractured, and not yet ready to define, collect, and exchange data in a generally computable sense. Wherever possible, implementers and/or specification writers should avoid using this element. Often, when used, the URL is a reference to an implementation guide that defines these special rules as part of it's narrative along with other profiles, value sets, etc.

May be used to represent additional information that is not part of the basic definition of the resource and that modifies the understanding of the element that contains it and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

A unique identifier assigned to this claim response.

Allows claim responses to be distinguished and referenced.

The purpose of this identifier.

Applications can assume that an identifier is permanent unless it explicitly says that it is temporary.

Identifies the purpose for this identifier, if known .

Allows the appropriate identifier for a particular context of use to be selected from among a set of identifiers.

An identifier for each RTPBC response that is assigned by and unique to the reponder

If the value is a full URI, then the system SHALL be urn:ietf:rfc:3986. The value's primary purpose is computational mapping. As a result, it may be normalized for comparison purposes (e.g. removing non-significant whitespace, dashes, etc.) A value formatted for human display can be conveyed using the Rendered Value extension. Identifier.value is to be treated as case sensitive unless knowledge of the Identifier.system allows the processer to be confident that non-case-sensitive processing is safe.

The status of this response (active)

Value is always 'active'

A code specifying the state of the resource instance.

Need to track the status of the resource as 'draft' resources may undergo further edits while 'active' resources are immutable and may only have their status changed to 'cancelled'.

The type of service for which pricing and coverage predetermination is being requested

Value is always 'pharmacy'

The type or discipline-style of the claim.

Some jurisdictions need a finer grained claim type for routing and adjudication.

A reference to a code defined by a terminology system.

Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labeled as UserSelected = true.

Allows for alternative encodings within a code system, and translations to other code systems.

The identification of the code system that defines the meaning of the symbol in the code.

The URI may be an OID (urn:oid:...) or a UUID (urn:uuid:...). OIDs and UUIDs SHALL be references to the HL7 OID registry. Otherwise, the URI should come from HL7's list of FHIR defined special URIs or it should reference to some definition that establishes the system clearly and unambiguously.

Need to be unambiguous about the source of the definition of the symbol.

A symbol in syntax defined by the system. The symbol may be a predefined code or an expression in a syntax defined by the coding system (e.g. post-coordination).

Need to refer to a particular code in the system.

A representation of the meaning of the code in the system, following the rules of the system.

Need to be able to carry a human-readable meaning of the code for readers that do not know the system.

The mode of processing being performed by the payer/PBM

Value is always 'predetermination'

Claim, preauthorization, predetermination.

This element is required to understand the nature of the request for adjudication.

No personally-identifiable information is included in this profile. Instead, the patient element is populated with a Data Absent Reason = 'masked'

The patient must be supplied to the insurer so that confirmation of coverage and service hstory may be considered as part of the authorization and/or adjudiction.

An Extension

Provides a reason why the expected value or elements in the element that is extended are missing.

An Extension

Source of the definition for the extension code - a logical name or a URL.

The definition may point directly to a computable or human-readable definition of the extensibility codes, or it may be a logical URI as declared in some other specification. The definition SHALL be a URI for the Structure Definition defining the extension.

Value of extension - must be one of a constrained set of the data types (see Extensibility for a list).

A reference to a location at which the other resource is found. The reference may be a relative reference, in which case it is relative to the service base URL, or an absolute URL that resolves to the location where the resource is found. The reference may be version specific or not. If the reference is not to a FHIR RESTful server, then it should be assumed to be version specific. Internal fragment references (start with '#') refer to contained resources.

Using absolute URLs provides a stable scalable approach suitable for a cloud/web context, while using relative/logical references provides a flexible approach suitable for use when trading across closed eco-system boundaries. Absolute URLs do not need to point to a FHIR RESTful server, though this is the preferred approach. If the URL conforms to the structure "/[type]/[id]" then it should be assumed that the reference is to a FHIR RESTful server.

The expected type of the target of the reference. If both Reference.type and Reference.reference are populated and Reference.reference is a FHIR URL, both SHALL be consistent.

The type is the Canonical URL of Resource Definition that is the type this reference refers to. References are URLs that are relative to http://hl7.org/fhir/StructureDefinition/ e.g. "Patient" is a reference to http://hl7.org/fhir/StructureDefinition/Patient. Absolute URLs are only allowed for logical models (and can only be used in references in logical models, not resources).

This element is used to indicate the type of the target of the reference. This may be used which ever of the other elements are populated (or not). In some cases, the type of the target may be determined by inspection of the reference (e.g. a RESTful URL) or by resolving the target of the reference; if both the type and a reference is provided, the reference SHALL resolve to a resource of the same type as that specified.

Aa resource (or, for logical models, the URI of the logical model).

A unique, non-personally identifiable code such as an anonymous account identifier

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.

Plain text narrative that identifies the resource in addition to the resource reference.

This is generally not the same as the Resource.text of the referenced resource. The purpose is to identify what's being referenced, not to fully describe it.

The date this resource was created.

Need to record a timestamp for use by both the recipient and the issuer.

No personally-identifiable information is included in this profile. Insurance information is not included because it could potentially be used to re-identify patients

To be a valid claim, preauthorization or predetermination there must be a party who is responsible for adjudicating the contents against a policy which provides benefits for the patient.

An Extension

Provides a reason why the expected value or elements in the element that is extended are missing.

An Extension

Source of the definition for the extension code - a logical name or a URL.

The definition may point directly to a computable or human-readable definition of the extensibility codes, or it may be a logical URI as declared in some other specification. The definition SHALL be a URI for the Structure Definition defining the extension.

Value of extension - must be one of a constrained set of the data types (see Extensibility for a list).

The RTPBC Request ID contained in the associated request

An identifier for the target resource. This is used when there is no way to reference the other resource directly, either because the entity it represents is not available through a FHIR server, or because there is no way for the author of the resource to convert a known identifier to an actual location. There is no requirement that a Reference.identifier point to something that is actually exposed as a FHIR instance, but it SHALL point to a business concept that would be expected to be exposed as a FHIR instance, and that instance would need to be of a FHIR resource type allowed by the reference.

When an identifier is provided in place of a reference, any system processing the reference will only be able to resolve the identifier to a reference if it understands the business context in which the identifier is used. Sometimes this is global (e.g. a national identifier) but often it is not. For this reason, none of the useful mechanisms described for working with references (e.g. chaining, includes) are possible, nor should servers be expected to be able resolve the reference. Servers may accept an identifier based reference untouched, resolve it, and/or reject it - see CapabilityStatement.rest.resource.referencePolicy.

When both an identifier and a literal reference are provided, the literal reference is preferred. Applications processing the resource are allowed - but not required - to check that the identifier matches the literal reference

Applications converting a logical reference to a literal reference may choose to leave the logical reference present, or remove it.

Reference is intended to point to a structure that can potentially be expressed as a FHIR resource, though there is no need for it to exist as an actual FHIR resource instance - except in as much as an application wishes to actual find the target of the reference. The content referred to be the identifier must meet the logical constraints implied by any limitations on what resource types are permitted for the reference. For example, it would not be legitimate to send the identifier for a drug prescription if the type were Reference(Observation|DiagnosticReport). One of the use-cases for Reference.identifier is the situation where no FHIR representation exists (where the type is Reference (Any).

The purpose of this identifier.

Applications can assume that an identifier is permanent unless it explicitly says that it is temporary.

Identifies the purpose for this identifier, if known .

Allows the appropriate identifier for a particular context of use to be selected from among a set of identifiers.

The RTPBC Request ID contained in the associated request

Populate with the Claim.identifier.value from the associated request

The outcome of processing. Either 'complete' (finished without errors) or 'error' (processing could not complete). The outcome is 'processed' if processing completes with a coverage determination, including when it is determined that the requested product is not covered. Otherwise, the outcome = 'error'.

Note: If a system or communication error occurs, an OperationOutcome is returned instead of a ClaimResponse

If the outcome = 'error', the .error composite must be populated.

The result of the claim processing.

To advise the requestor of an overall processing outcome.

Note providing clarifying information and/or support contact information. Available for both 'completed' and 'error' outcomes.

The responding payer/PBM determines when and how to populate.Recommended that a patient help desk phone number be included.

Corresponds to the Help Desk Support elements in the NCPDP RTPBC response message.

Composite containing cost and coverage for the requested product and pharmacy.

SHALL be populated when the .outcome = 'complete'.

The adjudication for items provided on the claim.

An Extension

This extension conveys benefit restrictions that may apply to a prescription product and pharmacy combination.

This extension conveys the formulary status that applies to the product.

This extension conveys the preference level that applies to the product.

This extension conveys the date on which a patient prescription will have passed the insurer's minimum consumption requirements and may be considered for dispensing.

This extension conveys the coverage associated with an RTPBC Response item or addItem.

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

Indicates that the information in this .item composite relates to the requested product and pharmacy.

Necessary to provide a mechanism to link the adjudication result to the submitted claim item.

Number referencing a Determination Note (.processNote) explaining the coverage status for this product + pharmacy combination.

Provides a condensed manner for associating human readable descriptive explanations for adjudications on the line item.

Patient cost and coverage details for the requested product and pharmacy.

The adjudication results conveys the insurer's assessment of the item provided in the claim under the terms of the patient's insurance coverage.

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

Identifies a component of the patient's financial responsibility for the product cost.

At least one .adjudication must contain a .category with the .code value 'total', representing the patient's total financial responsibility for the product. Note that returned balance amounts (e.g., accumulated deductible or remaining deductible) are calculated from the current member balance and reflect only the effect of the associated RTPBC request

RTPBC Patient Pay Categories

Corresponds to NCPDP C95-KQ Patient Pay Component Qualifier.

The amount associated with the Patient Pay Component (.adjudication.category).

For example: amount submitted, eligible amount, co-payment, and benefit payable.

Most adjuciation categories convey a monetary amount.

The patient pay component amount in terms of the specified currency.

Monetary values have their own rules for handling precision (refer to standard accounting text books).

The amount of the currency. The value includes an implicit precision in the presentation of the value.

ISO 4217 Currency Code.

Currencies

A code indicating the currency, taken from ISO 4217.

The first-tier service adjudications for payor added product or service lines.

Insurers may redefine the provided product or service or may package and/or decompose groups of products and services. The addItems allows the insurer to provide their line item list with linkage to the submitted items/details/sub-details. In a preauthorization the insurer may use the addItem structure to provide additional information on authorized products and services.

An Extension

This extension indicates that this added line item is to be interpreted as one of possibly multiple alternatives to the requested product or service. When isAlternative is true, the added line item is to be considered independently from any other added line items associated with the requested product or service

Set to true in all real-time pharmacy benefit check response .addItems.

This extension conveys benefit restrictions that may apply to a prescription product and pharmacy combination.

This extension conveys the formulary status that applies to the product.

This extension conveys the preference level that applies to the product.

This extension conveys the date on which a patient prescription will have passed the insurer's minimum consumption requirements and may be considered for dispensing.

This extension conveys the coverage associated with an RTPBC Response item or addItem.

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

Indicates that the information in this .item composite is an alternative to the requested product and pharmacy.

Because a maximum of one product is submitted per request, this value is always '1'.

Provides references to the claim items.

Reference to an Organization resource representing the priced pharmacy

Insurer may provide authorization specifically to a restricted set of providers rather than an open authorization.

A reference to a location at which the other resource is found. The reference may be a relative reference, in which case it is relative to the service base URL, or an absolute URL that resolves to the location where the resource is found. The reference may be version specific or not. If the reference is not to a FHIR RESTful server, then it should be assumed to be version specific. Internal fragment references (start with '#') refer to contained resources.

Using absolute URLs provides a stable scalable approach suitable for a cloud/web context, while using relative/logical references provides a flexible approach suitable for use when trading across closed eco-system boundaries. Absolute URLs do not need to point to a FHIR RESTful server, though this is the preferred approach. If the URL conforms to the structure "/[type]/[id]" then it should be assumed that the reference is to a FHIR RESTful server.

A product identifier for the medication. Either an NDC11 or an RxNorm code for a prescribable product (representing drug name, strength and dose form)

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

RTPBC prescribable product codes (NDC11 and RxNorm)

Necessary to state what was provided or done.

A reference to a code defined by a terminology system.

Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labeled as UserSelected = true.

Allows for alternative encodings within a code system, and translations to other code systems.

The identification of the code system that defines the meaning of the symbol in the code.

The URI may be an OID (urn:oid:...) or a UUID (urn:uuid:...). OIDs and UUIDs SHALL be references to the HL7 OID registry. Otherwise, the URI should come from HL7's list of FHIR defined special URIs or it should reference to some definition that establishes the system clearly and unambiguously.

Need to be unambiguous about the source of the definition of the symbol.

A symbol in syntax defined by the system. The symbol may be a predefined code or an expression in a syntax defined by the coding system (e.g. post-coordination).

Need to refer to a particular code in the system.

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.

Need to be able to carry a human-readable meaning of the code for readers that do not know the system.

The number of repetitions of a service or product.

Required when the product or service code does not convey the quantity provided.

The prescribed quantity in terms of the applicable billing unit of measure.

The implicit precision in the value should always be honored. Monetary values have their own rules for handling precision (refer to standard accounting text books).

Precision is handled implicitly in almost all cases of measurement.

Not allowed to be used in this context

How the Quantity should be understood and represented.

Need a framework for handling measures where the value is <5ug/L or >400mg/L due to the limitations of measuring methodology.

Pharmacy metric billing unit: GM (gram), ML (milliliter) or EA (each)

Billing quantity unit of measure

There are many representations for units of measure and in many contexts, particular representations are fixed and required. I.e. mcg for micrograms.

Number referencing a Determination Note (.processNote) explaining the coverage status for this product + pharmacy combination.

Provides a condensed manner for associating human readable descriptive explanations for adjudications on the line item.

Patient cost and coverage details for an alternative product and pharmacy combination.

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

Identifies a component of the patient's financial responsibility for the product cost.

At least one .adjudication must contain a .category with the .code value 'total', representing the patient's total financial responsibility for the product

RTPBC Patient Pay Categories

Corresponds to NCPDP C95-KQ Patient Pay Component Qualifier.

The amount associated with the Patient Pay Component (.adjudication.category).

For example: amount submitted, eligible amount, co-payment, and benefit payable.

Most adjuciation categories convey a monetary amount.

The patient pay component amount in terms of the specified currency.

Monetary values have their own rules for handling precision (refer to standard accounting text books).

The amount of the currency. The value includes an implicit precision in the presentation of the value.

ISO 4217 Currency Code.

Currencies

A code indicating the currency, taken from ISO 4217.

Additional coverage determination information for a product / pharmacy combination.

Provides the insurer specific textual explanations associated with the processing.

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

A number to uniquely identify a note entry.

Links to the .noteNumber elements in .item and .addItem

Necessary to provide a mechanism to link from adjudications.

The explanation or description associated with the processing.

Required to provide human readable explanation.

Errors encountered during the processing of the adjudication.

Must be populated when .outcome = 'error'

Need to communicate processing issues to the requestor.

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

A code identifying the reason that processing could not be completed.

RTPBC Error Codes

Required to convey processing errors.

A reference to a code defined by a terminology system.

Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labeled as UserSelected = true.

Allows for alternative encodings within a code system, and translations to other code systems.

The identification of the code system that defines the meaning of the symbol in the code.

The URI may be an OID (urn:oid:...) or a UUID (urn:uuid:...). OIDs and UUIDs SHALL be references to the HL7 OID registry. Otherwise, the URI should come from HL7's list of FHIR defined special URIs or it should reference to some definition that establishes the system clearly and unambiguously.

Need to be unambiguous about the source of the definition of the symbol.

A symbol in syntax defined by the system. The symbol may be a predefined code or an expression in a syntax defined by the coding system (e.g. post-coordination).

Need to refer to a particular code in the system.

A representation of the meaning of the code in the system, following the rules of the system.

Need to be able to carry a human-readable meaning of the code for readers that do not know the system.

Clarification of the reject cause.

Very often the text is the same as a displayName of one of the codings.

The codes from the terminologies do not always capture the correct meaning with all the nuances of the human using them, or sometimes there is no appropriate code at all. In these cases, the text is used to capture the full meaning of the source.

Unique ClaimResponse Resource Identifier assigned by the responding payer/PBM

An identifier for each RTPBC response that is assigned by and unique to the reponder

The status of this response (active)

Value is always 'active'

The type of service for which pricing and coverage predetermination is being requested

Value is always 'pharmacy'

The mode of processing being performed by the payer/PBM

Value is always 'predetermination'

No personally-identifiable information is included in this profile. Instead, the patient element is populated with a Data Absent Reason = 'masked'

A unique, non-personally identifiable code such as an anonymous account identifier

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.

No personally-identifiable information is included in this profile. Insurance information is not included because it could potentially be used to re-identify patients

The RTPBC Request ID contained in the associated request

The RTPBC Request ID contained in the associated request

Populate with the Claim.identifier.value from the associated request

The outcome of processing. Either 'complete' (finished without errors) or 'error' (processing could not complete). The outcome is 'processed' if processing completes with a coverage determination, including when it is determined that the requested product is not covered. Otherwise, the outcome = 'error'.

Note: If a system or communication error occurs, an OperationOutcome is returned instead of a ClaimResponse

If the outcome = 'error', the .error composite must be populated.

Note providing clarifying information and/or support contact information. Available for both 'completed' and 'error' outcomes.

The responding payer/PBM determines when and how to populate.Recommended that a patient help desk phone number be included.

Corresponds to the Help Desk Support elements in the NCPDP RTPBC response message.

Composite containing cost and coverage for the requested product and pharmacy.

SHALL be populated when the .outcome = 'complete'.

This extension conveys benefit restrictions that may apply to a prescription product and pharmacy combination.

This extension conveys the formulary status that applies to the product.

This extension conveys the preference level that applies to the product.

This extension conveys the date on which a patient prescription will have passed the insurer's minimum consumption requirements and may be considered for dispensing.

This extension conveys the coverage associated with an RTPBC Response item or addItem.

Indicates that the information in this .item composite relates to the requested product and pharmacy.

Number referencing a Determination Note (.processNote) explaining the coverage status for this product + pharmacy combination.

Patient cost and coverage details for the requested product and pharmacy.

Identifies a component of the patient's financial responsibility for the product cost.

At least one .adjudication must contain a .category with the .code value 'total', representing the patient's total financial responsibility for the product. Note that returned balance amounts (e.g., accumulated deductible or remaining deductible) are calculated from the current member balance and reflect only the effect of the associated RTPBC request

RTPBC Patient Pay Categories

Corresponds to NCPDP C95-KQ Patient Pay Component Qualifier.

The amount associated with the Patient Pay Component (.adjudication.category).

The patient pay component amount in terms of the specified currency.

Currencies

This extension indicates that this added line item is to be interpreted as one of possibly multiple alternatives to the requested product or service. When isAlternative is true, the added line item is to be considered independently from any other added line items associated with the requested product or service

Set to true in all real-time pharmacy benefit check response .addItems.

This extension conveys benefit restrictions that may apply to a prescription product and pharmacy combination.

This extension conveys the formulary status that applies to the product.

This extension conveys the preference level that applies to the product.

This extension conveys the date on which a patient prescription will have passed the insurer's minimum consumption requirements and may be considered for dispensing.

This extension conveys the coverage associated with an RTPBC Response item or addItem.

Indicates that the information in this .item composite is an alternative to the requested product and pharmacy.

Because a maximum of one product is submitted per request, this value is always '1'.

Reference to an Organization resource representing the priced pharmacy

A product identifier for the medication. Either an NDC11 or an RxNorm code for a prescribable product (representing drug name, strength and dose form)

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

RTPBC prescribable product codes (NDC11 and RxNorm)

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.

The prescribed quantity in terms of the applicable billing unit of measure.

Pharmacy metric billing unit: GM (gram), ML (milliliter) or EA (each)

Billing quantity unit of measure

Number referencing a Determination Note (.processNote) explaining the coverage status for this product + pharmacy combination.

Patient cost and coverage details for an alternative product and pharmacy combination.

Identifies a component of the patient's financial responsibility for the product cost.

At least one .adjudication must contain a .category with the .code value 'total', representing the patient's total financial responsibility for the product

RTPBC Patient Pay Categories

Corresponds to NCPDP C95-KQ Patient Pay Component Qualifier.

The amount associated with the Patient Pay Component (.adjudication.category).

The patient pay component amount in terms of the specified currency.

Currencies

Additional coverage determination information for a product / pharmacy combination.

Links to the .noteNumber elements in .item and .addItem

Must be populated when .outcome = 'error'