FHIR IG analytics| Package | hl7.fhir.us.carin-rtpbc |
| Resource Type | ClaimResponse |
| Id | ClaimResponse-rtpbc-claim-response-03.json |
| FHIR Version | R4 |
No resources found
No resources found
Note: links and images are rebased to the (stated) source
Generated Narrative: ClaimResponse rtpbc-claim-response-03
Language: en
Profile: RTPBC Response Using ClaimResponse
identifier: rtpbc-03-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-03
outcome: Processing Complete
disposition: Processed successfully
item
RTPBC benefitRestriction Extension: RTPBC Benefit Restriction Code System: prior-auth (Prior authorization required)
RTPBC formularyStatus Extension: RTPBC Formulary Status Code System: 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: covered (Covered)
RTPBC formularyStatus Extension: RTPBC Formulary Status Code System: 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
FHIR
FHIRsmith{
"resourceType": "ClaimResponse",
"id": "rtpbc-claim-response-03",
"meta": {
"profile": [
"http://hl7.org/fhir/us/carin-rtpbc/StructureDefinition/rtpbc-response-claimresponse"
]
},
"language": "en",
"text": {
"status": "extensions",
"div": "<!-- snip (see above) -->"
},
"identifier": [
{
"value": "rtpbc-03-response"
}
],
"status": "active",
"type": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/claim-type",
"code": "pharmacy",
"display": "Pharmacy"
}
]
},
"use": "predetermination",
"patient": {
"reference": "Patient/rtpbc-patient-03"
},
"created": "2025-12-11T11:20:59-05:00",
"insurer": {
"identifier": {
"value": "Pharmacy Plans US"
}
},
"request": {
"identifier": {
"value": "rtpbc-03"
}
},
"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",
"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/rtpbc-formulary-status",
"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",
"code": "copay",
"display": "Copay"
}
]
},
"amount": {
"value": 40,
"currency": "USD"
}
},
{
"category": {
"coding": [
{
"system": "http://hl7.org/fhir/us/carin-rtpbc/CodeSystem/rtpbc-patient-pay-type",
"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",
"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",
"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/rtpbc-formulary-status",
"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",
"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",
"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",
"code": "total",
"display": "Total patient responsibility"
}
]
},
"amount": {
"value": 70,
"currency": "USD"
}
}
]
}
]
}