CARIN Consumer Realtime Pharmacy Benefit Check Implementation Guide CI Build

CARIN Consumer Realtime Pharmacy Benefit Check - Local Development build (v0.1.00-DRAFT). See the Directory of published versions

SD.1 StructureDefinition-carin-rtpbc-ClaimResponse

title: StructureDefinition-carin-rtpbc-ClaimResponse-intro layout: default active: StructureDefinition-carin-rtpbc-ClaimResponse-intro —

This profile constrains the ClaimResponse resource to serve as the RTPBC Response in the consumer real-time pharmacy benefit check process. It uses the ClaimResponse’s “predetermination” processing mode

SD.1.1 Formal Views of Profile Content

Description of Profiles, Differentials, and Snapshots.

The official URL for this profile is: http://hl7.org/fhir/us/carin/StructureDefinition/carin-rtpbc-response

Published on Thu Oct 03 00:00:00 CDT 2019 as a draft by CARIN Alliance.

This profile builds on ClaimResponse

Summary

Mandatory: 9 elements (24 nested mandatory elements)
Must-Support: 51 elements
Fixed Value: 3 elements

Structures

This structure refers to these other structures:

Differential View

NameFlagsCard.TypeDescription & Constraintsdoco
.. ClaimResponse 0..*
... id S0..1stringUnique ClaimResponse Resource Identifier
... identifier S1..*IdentifierRTPBC Response Identifier
.... value S1..1stringUnique RTPBC response ID
... status S1..1codeResponse status
Fixed Value: active
... type S1..1CodeableConceptRequested Service Type
Fixed Value: As shown
.... coding1..1CodingCode defined by a terminology system
Fixed Value: (complex)
..... system1..1uriIdentity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/claim-type
..... code1..1codeSymbol in syntax defined by the system
Fixed Value: pharmacy
..... display1..1stringRepresentation defined by the system
Fixed Value: http://terminology.hl7.org/CodeSystem/claim-type
.... coding S1..*Coding
..... system S1..1uri
..... code S1..1code
... use S1..1codeProcessing Mode
Fixed Value: predetermination
... patient S1..1Reference(CARIN RTPBC Request Patient Info)Response Patient Information
... insurer S1..1Reference(CARIN RTPBC Request Coverage Identifiers)Pharmacy Coverage
... request S1..1Reference(Claim)Submitter's RTPBC Request ID
.... identifier S1..1Identifier
..... value S1..1stringRTPBC Request ID
... outcome S1..1codeProcessing Outcome
... disposition S0..1stringCompleted Note
... item S0..*BackboneElementRequested Product and Pharmacy
.... itemSequence S1..1positiveInt
.... noteNumber S1..*positiveIntDetermination Note Number
.... adjudication S1..*BackboneElementRequested Product and Pharmacy Determination
..... category S1..1CodeableConceptPatient Pay Component
Binding: CARIN RTPBC Patient Pay Category Value Set (required)
..... amount S1..1MoneyPatient Pay Component Amount
...... value S1..1decimalPatient Pay Amount Value
...... currency S1..1codePatient Pay Amount Currency
Binding: (unbound) (required)
... addItem 0..*BackboneElement
.... itemSequence S1..*positiveIntAssociated request Item Sequence
.... provider S1..*Reference(CARIN RTPBC Pharmacy)Priced Pharmacy
..... reference S1..1stringReference to Priced Pharmacy
.... productOrService S1..1CodeableConceptProduct
Binding: (unbound) (required)
..... coding S1..*Coding
...... system S1..1uri
...... code S1..1code
...... display S1..1stringProduct Description
.... quantity S1..1SimpleQuantityPriced Quantity
..... value S1..1decimalQuantity in Billing Units
..... unit S1..1stringBilling unit of measure
Binding: (unbound) (required)
.... noteNumber S1..*positiveIntDetermination Note Number
.... adjudication S1..*BackboneElementAlternative Product and Pharmacy Determination
..... category S1..1CodeableConceptPatient Pay Component
Binding: CARIN RTPBC Patient Pay Category Value Set (required)
..... amount S1..1MoneyPatient Pay Component Amount
...... value S1..1decimalPatient Pay Amount Value
...... currency S1..1codePatient Pay Amount Currency
Binding: (unbound) (required)
... processNote S0..*BackboneElementDetermination Note
.... number S1..1positiveIntDetermination Note Number
.... text S1..1stringDetermination Note Text
... error S0..*BackboneElementError Information
.... code S1..1CodeableConceptReject Reason
Binding: (unbound) (required)
..... coding S1..*Coding
...... system S1..1uri
...... code S1..1codeReject Code
...... display S1..1string
..... text S0..1stringReject Message

doco Documentation for this format

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. ClaimResponse I0..*Response to a claim predetermination or preauthorization
... id SΣ0..1stringUnique ClaimResponse Resource Identifier
... meta ΣI0..1MetaMetadata about the resource
... implicitRules ?!ΣI0..1uriA set of rules under which this content was created
... language I0..1codeLanguage of the resource content
Binding: CommonLanguages (preferred)
Max Binding: AllLanguages
... text I0..1NarrativeText summary of the resource, for human interpretation
... contained 0..*ResourceContained, inline Resources
... extension I0..*ExtensionAdditional content defined by implementations
... modifierExtension ?!I0..*ExtensionExtensions that cannot be ignored
... identifier SI1..*IdentifierRTPBC Response Identifier
.... id 0..1stringUnique id for inter-element referencing
.... extension I0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
.... use ?!ΣI0..1codeusual | official | temp | secondary | old (If known)
Binding: IdentifierUse (required)
.... type ΣI0..1CodeableConceptDescription of identifier
Binding: Identifier Type Codes (extensible)
.... system ΣI0..1uriThe namespace for the identifier value
Example General: http://www.acme.com/identifiers/patient
.... value SΣI1..1stringUnique RTPBC response ID
Example General: 123456
.... period ΣI0..1PeriodTime period when id is/was valid for use
.... assigner ΣI0..1Reference(Organization)Organization that issued id (may be just text)
... status ?!SΣI1..1codeResponse status
Binding: FinancialResourceStatusCodes (required)
Fixed Value: active
... type SΣI1..1CodeableConceptRequested Service Type
Binding: ClaimTypeCodes (extensible)
Fixed Value: As shown
.... id0..0stringUnique id for inter-element referencing
.... extension0..0ExtensionAdditional content defined by implementations
.... coding1..1CodingCode defined by a terminology system
Fixed Value: (complex)
..... id0..0stringUnique id for inter-element referencing
..... extension0..0ExtensionAdditional content defined by implementations
..... system1..1uriIdentity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/claim-type
..... version0..0stringVersion of the system - if relevant
..... code1..1codeSymbol in syntax defined by the system
Fixed Value: pharmacy
..... display1..1stringRepresentation defined by the system
Fixed Value: http://terminology.hl7.org/CodeSystem/claim-type
..... userSelected0..0booleanIf this coding was chosen directly by the user
.... text0..0stringPlain text representation of the concept
.... id 0..1stringUnique id for inter-element referencing
.... extension I0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
.... coding SΣI1..*CodingCode defined by a terminology system
..... id 0..1stringUnique id for inter-element referencing
..... extension I0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
..... system SΣI1..1uriIdentity of the terminology system
..... version ΣI0..1stringVersion of the system - if relevant
..... code SΣI1..1codeSymbol in syntax defined by the system
..... display ΣI0..1stringRepresentation defined by the system
..... userSelected ΣI0..1booleanIf this coding was chosen directly by the user
.... text ΣI0..1stringPlain text representation of the concept
... subType I0..1CodeableConceptMore granular claim type
Binding: ExampleClaimSubTypeCodes (example)
... use SΣI1..1codeProcessing Mode
Binding: Use (required)
Fixed Value: predetermination
... patient SΣI1..1Reference(CARIN RTPBC Request Patient Info)Response Patient Information
... created ΣI1..1dateTimeResponse creation date
... insurer SΣI1..1Reference(CARIN RTPBC Request Coverage Identifiers)Pharmacy Coverage
... requestor I0..1Reference(Practitioner | PractitionerRole | Organization)Party responsible for the claim
... request SΣI1..1Reference(Claim)Submitter's RTPBC Request ID
.... id 0..1stringUnique id for inter-element referencing
.... extension I0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
.... reference ΣI0..1stringLiteral reference, Relative, internal or absolute URL
.... type ΣI0..1uriType the reference refers to (e.g. "Patient")
Binding: ResourceType (extensible)
.... identifier SΣI1..1IdentifierLogical reference, when literal reference is not known
..... id 0..1stringUnique id for inter-element referencing
..... extension I0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
..... use ?!ΣI0..1codeusual | official | temp | secondary | old (If known)
Binding: IdentifierUse (required)
..... type ΣI0..1CodeableConceptDescription of identifier
Binding: Identifier Type Codes (extensible)
..... system ΣI0..1uriThe namespace for the identifier value
Example General: http://www.acme.com/identifiers/patient
..... value SΣI1..1stringRTPBC Request ID
Example General: 123456
..... period ΣI0..1PeriodTime period when id is/was valid for use
..... assigner ΣI0..1Reference(Organization)Organization that issued id (may be just text)
.... display ΣI0..1stringText alternative for the resource
... outcome SΣI1..1codeProcessing Outcome
Binding: ClaimProcessingCodes (required)
... disposition SI0..1stringCompleted Note
... preAuthRef I0..1stringPreauthorization reference
... preAuthPeriod I0..1PeriodPreauthorization reference effective period
... payeeType I0..1CodeableConceptParty to be paid any benefits payable
Binding: Claim Payee Type Codes (example)
... item SI0..*BackboneElementRequested Product and Pharmacy
.... id 0..1stringUnique id for inter-element referencing
.... extension I0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!ΣI0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... itemSequence SI1..1positiveIntClaim item instance identifier
.... noteNumber SI1..*positiveIntDetermination Note Number
.... adjudication SI1..*BackboneElementRequested Product and Pharmacy Determination
..... id 0..1stringUnique id for inter-element referencing
..... extension I0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!ΣI0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... category SI1..1CodeableConceptPatient Pay Component
Binding: CARIN RTPBC Patient Pay Category Value Set (required)
..... reason I0..1CodeableConceptExplanation of adjudication outcome
Binding: AdjudicationReasonCodes (example)
..... amount SI1..1MoneyPatient Pay Component Amount
...... id 0..1stringUnique id for inter-element referencing
...... extension I0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
...... value SΣI1..1decimalPatient Pay Amount Value
...... currency SΣI1..1codePatient Pay Amount Currency
Binding: (unbound) (required)
..... value I0..1decimalNon-monetary value
.... detail I0..*BackboneElementAdjudication for claim details
..... id 0..1stringUnique id for inter-element referencing
..... extension I0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!ΣI0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... detailSequence I1..1positiveIntClaim detail instance identifier
..... noteNumber I0..*positiveIntApplicable note numbers
..... adjudication I1..*Unknown reference to #ClaimResponse.item.adjudication
Detail level adjudication details
..... subDetail I0..*BackboneElementAdjudication for claim sub-details
...... id 0..1stringUnique id for inter-element referencing
...... extension I0..*ExtensionAdditional content defined by implementations
...... modifierExtension ?!ΣI0..*ExtensionExtensions that cannot be ignored even if unrecognized
...... subDetailSequence I1..1positiveIntClaim sub-detail instance identifier
...... noteNumber I0..*positiveIntApplicable note numbers
...... adjudication I0..*Unknown reference to #ClaimResponse.item.adjudication
Subdetail level adjudication details
... addItem I0..*BackboneElementInsurer added line items
.... id 0..1stringUnique id for inter-element referencing
.... extension I0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!ΣI0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... itemSequence SI1..*positiveIntAssociated request Item Sequence
.... detailSequence I0..*positiveIntDetail sequence number
.... subdetailSequence I0..*positiveIntSubdetail sequence number
.... provider SI1..*Reference(CARIN RTPBC Pharmacy)Priced Pharmacy
..... id 0..1stringUnique id for inter-element referencing
..... extension I0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
..... reference SΣI1..1stringReference to Priced Pharmacy
..... type ΣI0..1uriType the reference refers to (e.g. "Patient")
Binding: ResourceType (extensible)
..... identifier ΣI0..1IdentifierLogical reference, when literal reference is not known
..... display ΣI0..1stringText alternative for the resource
.... productOrService SI1..1CodeableConceptProduct
Binding: (unbound) (required)
..... id 0..1stringUnique id for inter-element referencing
..... extension I0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
..... coding SΣI1..*CodingCode defined by a terminology system
...... id 0..1stringUnique id for inter-element referencing
...... extension I0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
...... system SΣI1..1uriIdentity of the terminology system
...... version ΣI0..1stringVersion of the system - if relevant
...... code SΣI1..1codeSymbol in syntax defined by the system
...... display SΣI1..1stringProduct Description
...... userSelected ΣI0..1booleanIf this coding was chosen directly by the user
..... text ΣI0..1stringPlain text representation of the concept
.... modifier I0..*CodeableConceptService/Product billing modifiers
Binding: ModifierTypeCodes (example)
.... programCode I0..*CodeableConceptProgram the product or service is provided under
Binding: ExampleProgramReasonCodes (example)
.... serviced[x] I0..1Date or dates of service or product delivery
..... servicedDatedate
..... servicedPeriodPeriod
.... location[x] I0..1Place of service or where product was supplied
Binding: ExampleServicePlaceCodes (example)
..... locationCodeableConceptCodeableConcept
..... locationAddressAddress
..... locationReferenceReference(Location)
.... quantity SI1..1SimpleQuantityPriced Quantity
..... id 0..1stringUnique id for inter-element referencing
..... extension I0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
..... value SΣI1..1decimalQuantity in Billing Units
..... unit SΣI1..1stringBilling unit of measure
Binding: (unbound) (required)
..... system ΣI0..1uriSystem that defines coded unit form
..... code ΣI0..1codeCoded form of the unit
.... unitPrice I0..1MoneyFee, charge or cost per item
.... factor I0..1decimalPrice scaling factor
.... net I0..1MoneyTotal item cost
.... bodySite I0..1CodeableConceptAnatomical location
Binding: OralSiteCodes (example)
.... subSite I0..*CodeableConceptAnatomical sub-location
Binding: SurfaceCodes (example)
.... noteNumber SI1..*positiveIntDetermination Note Number
.... adjudication SI1..*BackboneElementAlternative Product and Pharmacy Determination
..... id 0..1stringUnique id for inter-element referencing
..... extension I0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!ΣI0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... category SI1..1CodeableConceptPatient Pay Component
Binding: CARIN RTPBC Patient Pay Category Value Set (required)
..... reason I0..1CodeableConceptExplanation of adjudication outcome
Binding: AdjudicationReasonCodes (example)
..... amount SI1..1MoneyPatient Pay Component Amount
...... id 0..1stringUnique id for inter-element referencing
...... extension I0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
...... value SΣI1..1decimalPatient Pay Amount Value
...... currency SΣI1..1codePatient Pay Amount Currency
Binding: (unbound) (required)
..... value I0..1decimalNon-monetary value
.... detail I0..*BackboneElementInsurer added line details
..... id 0..1stringUnique id for inter-element referencing
..... extension I0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!ΣI0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... productOrService I1..1CodeableConceptBilling, service, product, or drug code
Binding: USCLSCodes (example)
..... modifier I0..*CodeableConceptService/Product billing modifiers
Binding: ModifierTypeCodes (example)
..... quantity I0..1SimpleQuantityCount of products or services
..... unitPrice I0..1MoneyFee, charge or cost per item
..... factor I0..1decimalPrice scaling factor
..... net I0..1MoneyTotal item cost
..... noteNumber I0..*positiveIntApplicable note numbers
..... adjudication I1..*Unknown reference to #ClaimResponse.item.adjudication
Added items detail adjudication
..... subDetail I0..*BackboneElementInsurer added line items
...... id 0..1stringUnique id for inter-element referencing
...... extension I0..*ExtensionAdditional content defined by implementations
...... modifierExtension ?!ΣI0..*ExtensionExtensions that cannot be ignored even if unrecognized
...... productOrService I1..1CodeableConceptBilling, service, product, or drug code
Binding: USCLSCodes (example)
...... modifier I0..*CodeableConceptService/Product billing modifiers
Binding: ModifierTypeCodes (example)
...... quantity I0..1SimpleQuantityCount of products or services
...... unitPrice I0..1MoneyFee, charge or cost per item
...... factor I0..1decimalPrice scaling factor
...... net I0..1MoneyTotal item cost
...... noteNumber I0..*positiveIntApplicable note numbers
...... adjudication I1..*Unknown reference to #ClaimResponse.item.adjudication
Added items detail adjudication
... adjudication I0..*Unknown reference to #ClaimResponse.item.adjudication
Header-level adjudication
... total ΣI0..*BackboneElementAdjudication totals
.... id 0..1stringUnique id for inter-element referencing
.... extension I0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!ΣI0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... category ΣI1..1CodeableConceptType of adjudication information
Binding: AdjudicationValueCodes (example)
.... amount ΣI1..1MoneyFinancial total for the category
... payment I0..1BackboneElementPayment Details
.... id 0..1stringUnique id for inter-element referencing
.... extension I0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!ΣI0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... type I1..1CodeableConceptPartial or complete payment
Binding: ExamplePaymentTypeCodes (example)
.... adjustment I0..1MoneyPayment adjustment for non-claim issues
.... adjustmentReason I0..1CodeableConceptExplanation for the adjustment
Binding: PaymentAdjustmentReasonCodes (example)
.... date I0..1dateExpected date of payment
.... amount I1..1MoneyPayable amount after adjustment
.... identifier I0..1IdentifierBusiness identifier for the payment
... fundsReserve I0..1CodeableConceptFunds reserved status
Binding: Funds Reservation Codes (example)
... formCode I0..1CodeableConceptPrinted form identifier
Binding: Form Codes (example)
... form I0..1AttachmentPrinted reference or actual form
... processNote SI0..*BackboneElementDetermination Note
.... id 0..1stringUnique id for inter-element referencing
.... extension I0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!ΣI0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... number SI1..1positiveIntDetermination Note Number
.... type I0..1codedisplay | print | printoper
Binding: NoteType (required)
.... text SI1..1stringDetermination Note Text
.... language I0..1CodeableConceptLanguage of the text
Binding: CommonLanguages (preferred)
Max Binding: AllLanguages
... communicationRequest I0..*Reference(CommunicationRequest)Request for additional information
... insurance I0..*BackboneElementPatient insurance information
.... id 0..1stringUnique id for inter-element referencing
.... extension I0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!ΣI0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... sequence I1..1positiveIntInsurance instance identifier
.... focal I1..1booleanCoverage to be used for adjudication
.... coverage I1..1Reference(Coverage)Insurance information
.... businessArrangement I0..1stringAdditional provider contract number
.... claimResponse I0..1Reference(ClaimResponse)Adjudication results
... error SI0..*BackboneElementError Information
.... id 0..1stringUnique id for inter-element referencing
.... extension I0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!ΣI0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... itemSequence I0..1positiveIntItem sequence number
.... detailSequence I0..1positiveIntDetail sequence number
.... subDetailSequence I0..1positiveIntSubdetail sequence number
.... code SI1..1CodeableConceptReject Reason
Binding: (unbound) (required)
..... id 0..1stringUnique id for inter-element referencing
..... extension I0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
..... coding SΣI1..*CodingCode defined by a terminology system
...... id 0..1stringUnique id for inter-element referencing
...... extension I0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
...... system SΣI1..1uriIdentity of the terminology system
...... version ΣI0..1stringVersion of the system - if relevant
...... code SΣI1..1codeReject Code
...... display SΣI1..1stringRepresentation defined by the system
...... userSelected ΣI0..1booleanIf this coding was chosen directly by the user
..... text SΣI0..1stringReject Message

doco Documentation for this format

Downloads: StructureDefinition: (XML, JSON), Schema: XML Schematron