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Narrative

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Source1

{
  "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": "<!-- snip (see above) -->"
  },
  "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-03"
  },
  "created": "2019-11-01T11:20:59-05:00",
  "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": "not-covered",
            "display": "Not covered"
          }
        }
      ],
      "itemSequence": 1,
      "adjudication": [
        {
          "category": {
            "coding": [
              {
                "system": "http://hl7.org/fhir/us/carin-rtpbc/CodeSystem/rtpbc-patient-pay-type",
                "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",
            "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",
            "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",
                "code": "copay",
                "display": "Copay"
              }
            ]
          },
          "amount": {
            "value": 405,
            "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": 469,
            "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": 874,
            "currency": "USD"
          }
        }
      ]
    }
  ],
  "processNote": [
    {
      "number": 1,
      "text": "Quantity limit: 28 tablets per month"
    }
  ]
}